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A 



PEACTICAL TREATISE 



DISEASES OF CHILDREN 



PRACTICAL TREATISE 



DISEASES OF CHILDREN. 



BY 



J. FORSYTH MEIGS, M. D, 

One of the Physicians to the Pennsylvania Hospital; Consulting Physician to the 

Children's Hospital ; Fellow of the College of Physicians of Philadelphia ; 

Member of the American Philosophical Society, of the Academy 

of Natural Sciences of Philadelphia, of the Pathological 

Society, of the Obstetrical Society, etc. etc. 



WILLIAM PEPPEE, M.D., 

Lecturer on Clinical Medicine in the University of Pennsylvania; Physician to the 
Philadelphia Hospital, and to the Children's Hospital ; Fellow of the 
College of Physicians of Philadelphia ; President of the Patho- 
logical Society; Member of the American Philosophical 
Society, of the Academy of Natural Sciences, 
OF the Obstetrical Society, etc. etc. 



"tJ^" Jftlt (Bdition, 



EEYISED AKD ENLARGED. 




%H[nG' 



PHILADELPHIA: 
LINDSAY & BLAKISTOK 

18 74. 






Entered according to Act of Congress, in the year 1874, 

By LINDSAY & BLAKISTOX, 

In the Office of the Librarian of Congress, at Washington, D. C. 



SHERMAN & CO., PRINTERS, PHILADELPHIA. 



TO 



GEOEGE B. WOOD, M.D., LL.D., 

President of the College of Physicians of Philadelphia ; Emeritus Professor of the Theory and Practice 

of Medicine in the University of Pennsylvania ; late one of the Physicians to the 

Pennsylvania Hospital, &c. &c., 

@:i)i5 tXlork is IBebicateir, 

AS 

A TRIBUTE OF RESPECT FOR HIS HIGH PROFESSIONAL ATTAINMENTS 

AND 

EMINENT PRIVATE VIRTUES, 

AND AS 

A MARK OF GRATITUDE FOR HIS VALUABLE INSTRUCTIONS, 

BY 

THE AUTHORS, 



J. Forsyth Meigs, 
William Pepper. 



PREFACE 

TO THE FIFTH EDITIOK 



Owing to the comparatively short time which has elapsed since 
the appearance of the last edition of this work, it has not been 
thought necessary to introduce any extensive changes in many parts 
of the text. All of it has, however, been subjected to careful revi- 
sion, and such modifications made as were called for by changes in 
our own views, or by the results of the recent researches of others. 
In addition to this, several important articles have been almost 
entirely rewritten ; among which may be mentioned that on the 
Diseases of the Heart ; on Progressive Muscular Sclerosis ; on the 
treatment of Scarlet Fever, and of Measles ; on Variola, and on the 
Vaccine Disease. 

Some of the articles which seem appropriate in a systematic work 
on the diseases of children, but which were unavoidably omitted 
in the last edition, have been supplied. Among these will be found 
articles on Pulmonary Emphysema, Pneumothorax, Affections of 
the Tonsils, Retro-pharyngeal Abscess, Malarial Fevers, and Scrof- 
ula. To obviate the increase in the size of the work necessitated 
by these additions, most of the illustrative cases, the number of 
which has been considerably increased, have been placed in smaller 
type, and in many places the former text has been condensed. De- 
spite these changes, however, an increase of ninety pages has resulted 
from the large amount of new matter added. On the whole, it is 
felt that the hope may reasonably be entertained that the work in 
its present form will prove of more practical utility than hereto- 
fore, and will continue to serve the purpose, which has actuated its 
authors, of facilitating the study and treatment of this interesting 
and important class of diseases. 

Philadelphia, January, 1874. 



PREFACE 

TO THE FOURTH EDITIOK 



It has been some years since the third edition of Meigs on the 
Diseases of Childreii has been exhausted; and the frequent inquiries 
which have been made for the work, as well as the increasing 
interest taken by the profession in the study of the diseases of 
childhood, have led to the belief that the publication of a new 
edition would be received with the same kind favor which has been 
already extended to the three former ones. 

The changes and additions which were necessitated by the great 
advance made during the last decade in our knowledge of a number 
of the diseases of children, as well as by the unavoidable omission 
of any consideration of several important subjects in the previous 
editions of this work, were, however, of so extensive a character 
that it has been found necessary to associate a collaborator in the 
preparation of the present edition. 

Among the principal of these changes may be mentioned the 
great enlargement of several articles, and especially of those on 
thrush, convulsions, chorea, tracheotomy in croup, and parasitic 
skin diseases. Other articles have been entirely rearranged, or 
even rewritten, as those upon the diseases of the stomach and 
intestines, and upon eczematous affections. In addition to such 
changes, however, there have been no less than seventeen full arti- 
cles added, embracing the following important subjects : Diseases 
of the heart, and cyanosis ; diseases of the coecum and appendix 
vermiformis, and intussusception ; chronic hydrocephalus, tetanus, 
atrophic infantile paralysis, facial paralysis, and progressive paraly- 
sis with apparent hypertrophy of the muscles ; rheumatism, diph- 
theria, mumps, rickets, tuberculosis, and infantile syphilis ; typhoid 
fever; and sclerema. These various additions and changes have 
involved the introduction of more than two hundred pages of new 



X PREFACE TO THE FOURTH EDITION. 

matter. Several extensive tables, exhibiting the mortality in this 
city of some of the most common and fatal diseases, in connection 
^vith the variations of temperature, have been prepared with great 
care from the records of the office of the Board of Health, which 
were opened to examination through the courtesy of Mr. Chambers, 
the Chief Registration Clerk of that office. A copious index has 
also been supplied, which it is trusted will facilitate reference, and 
render the work more practically serviceable. 

Apart from these changes, however, no alteration has been made 
in the general plan of the work. As in the composition of the 
previous editions, the best and most recent foreign and domestic 
authorities on the diseases of children have been frequently and 
carefully consulted, and their views fully quoted whenever they 
appeared of practical importance. For the most part, however, 
the opinions expressed in the following pages are those to which 
the authors have been led hy their personal observation, and which 
they therefore believe to have been approved by the most searching 
of all tests, that of practical application. 

It has also been their constant aim, while supplying a sufficient 
amount of information upon questions of etiology, pathology, and 
morbid anatomy, to insure a practical character to the work. With 
this view, an unusual amount of space has been devoted to the dis- 
cussion of the treatment of the different diseases, and in every 
instance the conclusions derived by the authors from their own 
experience have been fully, and, it is hoped, clearlj^ stated. 

In so doino- it has been necessarv to consider somewhat at leno^th 
the extremely important questions of the employment of venesec- 
tion, antimony, calomel, and stimulants; and a full expression of 
opinion upon each of these points will be found in its appropriate 
place. 

In conclusion, the authors would venture to express the hope 
that their efforts may have been successful in furnishing a work 
which will aid in rendering the study of the diseases of children 
more attractive and clear, their recognition more easy, and which 
may serve as a practical guide in the difficult task of treating these 
disorders. 

Philadelphia, February, 1870. 



TABLE OF CONTENTS 



PAGE 

Preface to the Fifth Editiok, vii 

Preface to the Fourth Edition, . . . \ . . . ix 
Ixtroditctory Essay, 17 



CLASS I. 

DISEASES OF THE RESPIRATORY ORGANS. 

CHAPTEE I. 

DISEASES OF THE UPPER AIR-PASSAGES. 

SECTION I. 
Article I. Coryza, 52 

SECTION II. 
diseases of the larynx. 

General Eemarks, 61 

Article I. Simple laryngitis without spasm. 63 

" II. Spasmodic simple laryngitis, 69 

" III. Pseudo-membranous laryngitis, 86 

CHAPTEE 11. 

diseases of the lungs and pleura. 

General Eemarks, 134 

Article I. Atelectasis pulmonum, . . 135 

" II. Pneumonia, 159 

" III. Bronchitis, 196 

" IV. Emphysema, 220 

" V. Pleurisy, 233 

" YI. Pneumothorax, 253 

" YII. Hooping-cough, 259 



xii TABLE OF CONTENTS. 

CLASS 11. 

DISEASES OF THE CIRCULATORY ORGANS. 

PAGE 

Article I. Cyanosis, 281 

" II. Diseases of the heart, 290 



CLASS IIL 

DISEASES OF THE DIGESTIVE ORGANS, 

CHAPTER I. 

DISEASES or THE MOUTH AND THROAT. 

Article I. Simple or erythematous stomatitis, 301 

" II. Aphtha, 302 

" III. Ulcerative or ulcero-memhranous stomatitis, . . . 305 

" TV. Gangrene of the mouth, 309 

" Y. Thrush, 321 

" YI. Affections of the Tonsils, 344 

" YII. Simple or erythematous pharyngitis, 348 

" YIII. Retro-pharyngeal abscess, 354 

CHAPTER II. 

diseases of THE STOMACH AND INTESTINES. 

General Remarks, 356 

sectio:n^ I. 

FUNCTIONAL DISEASES OR MILD CATARRH OF THE STOMACH AND 

INTESTINES. 

Article I. Indigestion, 356 

" II. Simple diarrhoea, , , . . 367 

SECTION II. 

DISEASES OF THE STOMACH AND INTESTINES, ATTENDED WITH APPRE- 
CIABLE ANATOMICAL ALTERATIONS. 

Article I. Gastritis, 377 

" II. Entero-colitis, or inflammatory diarrhoea, .... 383 



TABLE OF CONTENTS. Xlll 

PAGE 

Article III. Cholera infantum, 421 

'' IV. Dysentery, 442 

" y. Diseases of the coecum and appendix coeci, . . . 447 

" TI. Intussusception, 462 



CLASS IV. 

DISEASES OF THE NERVOUS SYSTEM. 

Gexeral Remarks, 478 

Article L Tubercular meningitis, 479 

" II. Simple meningitis, . 507 

" III. Cerebral congestion, 515 

" lY. Cerebral hemorrhage, 519 

" V. Chronic hydrocephalus, 528 

" YI. General convulsions or eclampsia, 537 

" YII. Laryngismus stridulus, 557 

"YIII. Contraction with rigidity, 574 

" IX. Tetanus, 582 

" X. Chorea, 591 

" XI. Atrophic infantile paralysis, 615 

" XII. Facial paralysis, 633 

"XIII. Progressive muscular sclerosis, or pseudo-hypertrophic 

muscular paralysis, 634 



CLASS V. 

GENERAL DISEASES -CONSTITUTIONAL AND ZYMOTIC. 

I:5^TR0DTJCT0RT Eemarks, ' . . 646 

Article I. Rheumatism, 646 

" II. Diphtheria, 651 

" III. Mumps, 685 

" I Y. Malarial fever, 690 

" Y. Scarlet fever, or scarlatina, 694 

" YI. Measles, or rubeola, or morbilli, 758 

" YII. Small-pox, or variola, 781 

"YIII. Yaccine disease, ! . . 804 

" IX. Yaricella, 819 

" X. Typhoid fever, 822 



xiv TABLE OF CONTENTS. 

CLASS VI. 

CACHECTIC DISEASES. 

PAGE 

Article I. Scrofula, 836 

" II. Tuberculosis, 842 

" III. Rickets, 858 

" TV. Congenital syphilis, 870 



CLASS VIL 

DISEASES OF THE SKIN. 
INTRODIJCTORY REMARKS, 877 

CHAPTER I. 

RASHES. 

Article I. Erythema, . 878 

" II. Erysipelas, 883 

" III. Roseola, 891 

" lY. Urticaria, 894 



CHAPTER II. 

VESICLES. 

Article I. Eczematous affections, 898 

" II. Herpes, 913 

" III. Scabies, 919 

CHAPTER III. 
bull^. 

Article I. Pemphigus or Pompholyx, 923 

" II. Rupia, 926 

CHAPTER lY. 

PUSTULES. 

Article I. Ecthyma, 929 



TABLE OF CONTENTS. XV 

CHAPTER Y. 

PAPULES. 

PAGE 

Article I. Strophulus, 931 

'• II. Lichen, 933 

" III. Prurigo, 934 

CHAPTER YI. 
Squamge, . . " . 936 

CHAPTER YII. 

DISEASES NOT CLASSIFIED AMONG THE PRECEDING. 

SECTION I. 

parasitic diseases of the skin". 

Gexeral Remarks, 937 

Article I. Favus, 941 

" II. Tinea, 948 

" III. Alopecia areata, 954 

• SECTIO:^' II. 
Article L Sclerema, . 956 



CLASS VIIL 

WORMS IN THE ALIMENTARY CANAL. 
GrEN:ERAL REMARKS, 961 

Article I. Ascaris lumbricoides, 965 

" II. Ascaris vermicularis, 977 



A 

PRACTICAL TREATISE 

ON THE 

DISEASES OF CHILDREN, 



USTTEODUCTOEY ESSAY. 
OX THE CLINICAL EXAMINATION OF CHILDKEN. 

The clinical examination of children, and particularly of young infants, 
cannot be successfully practiced upon the same method as that habitually 
made use of in the case of adults. The truth of this statement will be 
readily assented to by all who have had much experience in the treatment 
of the diseases of the two ages, by those who will reflect for a moment on 
the great differences in the expressions of the various organs in early and 
adult life, and by those who are acquainted with the opinions of distin- 
guished writers upon children's diseases. It is proper and useful, there- 
fore, to preface a practical work on the diseases of children, with a sketch 
or plan of the best m.ethod to be pursued in forming a diagnosis of these 
diseases, and with remarks upon the physiological characters which dis- 
tinguish the organization of early life from that of maturity. 

The difficulties that beset the path of the practitioner in his clinical ex- 
amination of children are so great that he who has not been prepared by 
preliminar}^ study to surmount these obstacles, will find it a most uncer- 
tain and dubious task to unravel the history and nature of any case that 
may be set before him. The helpless silence of the infant, — the wilful 
silence, or the loose and inconsistent answers of the older child, which 
lead astray the mind rather than guide it to true results, — the agitation 
and fright produced by the examination, rendering it impossible at times 
to ascertain the real stateof the different functionsof the economy, — and, 
lastly, the difficulty of obtaining accurate and reliable accounts of the his- 
tory of the case from the attendants, all combine to make the duty of the 
phj'sician most perplexing, and, unless he be gifted with a large share of 
patient and philosophic calmness, most irksome and trying to the temper. 
So great, indeed, are the difficulties encountered by some practitioners 
who enter upon this branch of the practice of medicine without proper 

2 



18 INTRODUCTORY ESSAY. 

preliminary preparation, that they never overcome them; but, to use the 
words of Dr. West, "grow satisfied with their ignorance, and will then, 
with the greatest gravity, assure you that the attempt to understand 
these affections is useless." That it is possible, however, to overcome, 
in great measure, these obstacles, and to arrive at a correct diagnosis in 
nearly all cases, is quite as true as that these obstacles really exist. But, 
in order to do this, the ph3'sician must first be aware that difficulties 
exist, and must have foi'raed in his mind some plan or method by which 
to surmount or elude them. 

Before proceeding to show what is the best method of examining or 
exploring disease in children, we must state that our remarks apply 
chiefly to infants and ver^' 3'oung subjects; for, after the age of eight and 
ten years, the physical and intellectual development have progressed to 
such a point as to render the method of diagnosis nearly the same as 
that emploj^ed in adults. 

The chief causes which render the diagnosis of disease in young chil- 
dren difficult, are the absence of the faculty of speech, and the violent 
agitation generally caused bj^the examination, which prevents a proper 
appreciation of the state of certain organs and functions. 

It is easy to understand how much our means of diagnosis are restricted 
by the absence of the faculty of speech. How many symptoms are there 
in the case of adults with which we become acquainted only through the 
patient's own account of his sensations; and, consequently, of how many 
must we be deprived in children by the absence of this account! It 
might, indeed, at first view, seem impossible to detect the nature of the 
sickness without the assistance of this means, so greatly do we depend 
upon it in our examinations of adults. Nevertheless, we shall find our- 
selves enabled, by an attentive consideration of other resources in the 
child, by a close study of its physiognomical expression, its decubitus, 
the nature of its cry, and by the most rigidly careful physical examina- 
tion, tj form our conclusions with almost as great a degree of precision 
as in older patients. 

The other causes of difficulty, — the violent disturbance, both physical 
and moral, of the child, its fright, agitation, and cries, — constitute, when 
they are present in a high degree, much greater embarrassments than the 
want of speech. To overcome these, the physician must use all his skill, 
tact, and patience; for, unless they can be avoided by art, or overcome 
by soothing and gentle persuasion, he can learn but little that will be of 
essential service to hina in making up his opinion. He can neither read 
the countenance of the little patient, nor judge by its attitudes or decu- 
bitus of the state of the various organs, whether internal or external; 
he will be unable to ascertain the. rate, force, or regularity of the circu- 
latory or respiratory functions; he cannot, to any useful purpose, ex- 
amine the abdomen, to learn whether it be tender on pressure, or 
whether its contained organs be in their natural condition as to size 
and position ; and, lastly, he will find that the physical exploration of 
the lungs and heart, by auscultation and percussion, yield him at best 
only imperfect results. 



METHOD OF DIAGNOSIS. 19 

To avoid the difficulties just detailed, it is always useful, if not abso- 
lutely necessary, to conduct certain portions of the examination whilst 
the child is calm and quiet, and certain others whilst it is disturbed and 
agitated. This distinction of the examination into two periods, or 
stages, is one of the utmost importance in a practical point of view, and 
should never be forgotten by the physician during his clinical observa- 
tion of the various symptoms the patient may present. 

By the period of calm is meant a condition of total quiescence, in 
which the child is undisturbed either by internal or external causes of 
irritation. This condition is best found in the state of sleep. If this 
cannot be obtained, the one most nearlj^ approaching to it is that which 
exists during the act of nursing, or which follows that act. Suckling 
is usually followed, even in the sick child, by a condition of drowsiness 
or by a gentle and languid slumber, during which it will allow a care- 
ful examination upon many points without agitation. If possible, 
therefore, the physician should always see the child when asleep, and 
if the mother or nurse propose, on the occasion of his visit, to hurry 
up stairs to prepare the child, or to bring it down into the parlor or 
lower room, he should ask, as a favor, that he may see it asleep. 

If, in spite of having just been nursed, the child be awake and fret- 
ting, and when, also, it is more advanced in age, we should endeavor, 
by the attraction of toys, by gentle and soothing words and manners, 
by fondling, or by having it carried about the room, to get it quiet. 

Before proceeding to a consideration of the particular means by which 
we are to judge of the state of health or sickness of young subjects, it 
is proper to call attention to the great importance of a careful examina- 
tion of the attendants, in regard to the history of the case, previous to 
and between the medical visits. In the instance of children, their in- 
ability to describe their own symptoms compels us to depend entirely 
upon the mother or nurse for all detail of the case previous to our first 
visit, and for all accounts of what may have happened between two 
subsequent ones. It is, therefore, extremely important that this part 
of the examination should be conducted with every care and caution. 
Yery much that is useful may be learned from it, if it be well managed. 
A great deal of skill and art are required in putting the questions, and 
in sifiing the evidence thus collected. We should always bear in mind 
the character of the persons questioned. Much depends upon their 
education, and much more on their natural powers of observation, and 
manner of relating what they may have seen. The degree of credence 
to be attached to their answers must rest upon their probable intel- 
ligence. Nurses and mothers will often give accounts of their charges 
which must be received with large allowance, and even in some few in- 
stances with disbelief We would, however, in this place, most earnestly 
caution the young practitioner of medicine to be very careful not to 
misbelieve, or even mistrust, without well-poised reasons, the account 
of a sick child given by a mother; for though a foolish, weak woman 
will often give a false or exaggerated statement of the symptoms of her 
child, an observant and intelligent, and sometimes a foolish and weak 



20 INTRODUCTORY ESSAY. 

one, -when guided by maternal instinct, will detect variations from the 
healthful condition of a child, which may entirely escape the search of 
the most acute and rigorous medical observer. A mother may perceive 
a change in the expression of the face, in the manner of the muscular 
movements, in the temper or conduct of her child, which shall fail to 
attract the attention of the practitioner; or it maj^ be that the symp- 
tom which has caused the parent to take alarm occurs only during the 
absence of the physician. The medical attendant ought, for these 
reasons, to listen patienth' and kindly to whatever the mother or nurse 
may have to say, and if unable to detect immediately what they assert 
they have seen, let him not determine at once that there has been a 
mistake, that their anxiety has deceived them ; but let him examine 
the patient 3^et again, and more carefully, or let him pay another visit 
to learn whether the symptom or sjmiptoms continue, or have occurred 
again. Our own rule, in a doubtful case, is to listen with religious at- 
tention to the mother, and unless she be far beneath the average of 
human intelligence, our opinion as to the fact of some deviation from 
the ordinary health of the child is considerably influenced by what she 
tells us. 

The inquiry in regard to the history of the case, previous to the first 
visit of the physician, should bear particularly upon the causes of the 
sickness, its precise moment and mode, of attack, and its course and 
sj-mptoms up to the present time. The most important points to be 
considered in connection with these objects, are the health of the 
parents, including their ordinary health, or their habitual diseases, the 
causes and periods of their death, if they are not living, and the state 
of health of the child at the moment of birth and since. The hygi- 
enic conditions in which the patient has been placed ought always to 
be investigated ; the place of habitation -, the kind of house, and whether 
a large well-ventilated room, or a small, narrow, and close one; the 
clothing; the food ; and lastly, whether the infant has been suckled, 
or brought up on artificial diet. The state of the health just anterior 
to the attack ought always to be examined into. Has it been good 
and strong, or feeble and delicate ? If delicate, what diseases ? If the 
approach of any of the eruptive fevers be suspected from the character 
of the symptoms, the question as to whether the child has previously 
had measles or scarlet fever, or has been vaccinated or had variola, 
should always be asked. 

It is next necessary to fix as accurately as possible, the precise period 
of the onset of the sickness. If the question, " When was the child 
taken sick ?" be asked, as it usually is, the answer will be, " Oh, several 
da,ys ago," or, " I don't recollect exactly — I think yesterday, or the 
day before," or some such loose answer. The best way to learn the 
exact period in a recent case, is to go back, day by day, or else to in- 
quire as to some particular day. We may ask, was the child quite well 
daj' before yesterday; was it well last Sunday? did it play and amuse 
itself? was it as gay and good-tempered as usual yesterday, or the day 
before, or the day before that? Did it sleep well night before last, or 



DIAGNOSIS OF ANTECEDENTS. 21 

the night before that? A sick child never scarcely sleeps well at night, 
and very often we may learn by close inquiry into this particular, the 
exact time at which the attack began. In this way, by forcing the 
attendant to tax her memory, and to go minutely over the events of 
the several da^'S previous, we shall nearly always succeed in fixing very 
precisely the moment of onset. 

Having determined these points, we should proceed to inquire in re- 
gard to the course of the disease prior to the first visit. This is to be 
done only by patient and repeated questioning. The questions must 
be so fi'amed as to elicit free and unbiassed answers. They should be 
general, and not leading. Lastly, we are to inquire into the treatment 
of the case up to the present time. 

It is best that all these interrogatories should be made previous to 
seeing the child, in some other room than the nursery, in order to avoid 
the risk of alarming the child by the presence, during an unnecessary 
length of time, of a stranger. If, however, the child be well acquainted 
with the physician, it matters not where the inquiries are made. 

Having now obtained from the attendants all the information they 
can give in regard to the history and nature of the case, the phj^sician 
must proceed to the personal examination of the patient, in order to 
determine, by his own observation, the exact nature of the sickness, 
and the treatment it may require. 

The most important points to be attended to during the clinical exam- 
ination, are the countenance or facies, noting its expression, coloration, 
the presence or absence of furrows and wrinkles from pain, from emacia- 
tion, ^or from disordered muscular action, the appearances presented by 
the nasal orifices, and especially by the alse nasi, and the characters ex- 
hibited by the mouth; the sleep; the cry; the state of embonpoint or 
emaciation; the condition of the skin as to coloration, temperature, 
moisture or dryness, the presence of swellings of any kind, such as 
those produced by dropsy or by affections of the joints, and the exist- 
ence of eruptions; the pulse; impulse of the heart; the respiration; the 
signs furnished by the state of the mouth and throat, and by the dis- 
position towards and power of sucking, or by the manner in which 
drinks are taken; and lastly, the state of the abdomen. 

The Countenance. — The countenance of a young and healthy infant, 
who is sleeping or perfectly quiet, wears no expression except that of 
comfort and content. It is composed and still; no movement disturbs 
its innocent tranquillity, unless, perhaps, some gentle smile light it up 
from time to time, when we might well believe the happy superstition 
of the fond mother, who will tell us that angels are whispering it. In 
sickness, even when slight, the countenance soon loses this expression- 
less character. In all acute disorders the alteration is very great, such 
indeed as to strike the most careless and inexperienced observer. The 
features become contracted, furrows and wrinkles appear about the 
forehead, the nostrils are dilated, or pinched and thin, and the mouth 
becomes drawn and rigid. The extent of the change is generally in 
proportion to the severity of the attack. The part of the face most 



22 INTRODUCTORY ESSAY. 

altered will depend very much upon the j^articular system of organs 
implicated in the disease. 

Some authors have endeavored to show that different diseases give to 
the physiognomy certain peculiar and characteristic expressions. This 
is true only to a certain extent. Thus, the facies is very different in ab- 
dominal from that observed in thoracic or cerebral diseases; but though 
it is generally easy for a practiced physician to distinguish by the facies 
alone between a cerebral and thoracic disorder, it is quite impossible 
for him to distinguish between any two cerebral, thoracic, or abdominal 
affections. The particular changes impressed upon the face by differ- 
ent diseases cannot, however, be discussed in this place, but must be 
considered in the separate articles upon each disease. Here it can only 
be stated in general terms, that, in diseases of the brain, the upper part 
of the face, the forehead, and the eyes are chiefly affected; that in dis- 
eases of the thoracic organs, the middle portion of the face, and espe- 
cially the nostrils; while in those of the digestive organs, the lower 
part of the face, the mouth and lips, are the parts which undergo the 
greatest changes in their expression. 

Pain may almost alwaj^s be detected by the expression of the face. It 
gives to the countenance various shades of expression, according to its 
degree of severity, and its permanency or recurrence at intervals. Pain 
in the head is said, by Dr. M. Hall, to produce a contracted brow, pain 
in the belly to occasion an elevation of the upper lip, whilst pain in 
the chest is chiefly denoted by sharpness of the nostrils. We doubt, 
however, whether pain in any particular organ imparts an expression 
to one part of the face rather than to another, for indeed pain in any 
part of the body, whether the head, chest, abdomen, or limbs, gives rise 
to a contraction of all the features. JN'ot one part of the face alofte, but 
the forehead, mouth, nose, and the whole face, become changed in ex- 
pression and contracted, when there is severe pain in any part of the 
body, so that we deem it impossible from the expression alone, to de- 
termine where the painful sensation may be seated. The countenance 
merely tells us there is pain, but not where it is located. The painful 
expression will be permanent or occasional, as the pain itself is constant 
or only paroxj^smal. 

The coloration of the face becomes often an important means of diag- 
nosis. In all the fevers, phlegmasise, and diseases of general excitement, 
the face will be more or less suffused and red, unless the attack be so 
severe as to occasion a violent shock to the nervous system, in which 
event the countenance instead of being suffused, is paler than natural. 
In such cases the face becomes of a dead white, all traces of red disap- 
pear, and the skin at the same time has often a slightly shining or var- 
nished appearance. We have not unfrequently observed this symptom 
in pneumonia and bronchitis, and also in the latter stages of true croup. 
It is a very striking phenomenon, and one which portends great danger. 

In chronic cases of all kinds in which the hematosic and nutritive 
functions are enfeebled, the face assumes a pallid and waxen hue, which 
is very characteristic. In the various digestive ailments it becomes 



SIGNS FROM THE SLEEP. 23 

icterode or sallo^Y. and in affections of the liver more or less yellow. 
Lastly, in certain diseases and malformations of the heart or lungs, it 
becomes bluish or livid, constituting one of the most important signs of 
what is called morbus cceruleus, blue disease, or cyanosis. 

In reading the countenance of a sick child, the practitioner should 
always notice the play of the nostrils, since this reveals, to a certain 
extent, the state of the lungs. In pneumonia, bronchitis, and pleurisy, 
the movements of the alse nasi become rapid and energetic, expressing, 
by the degree of their violence and extent, the amount of embarrass- 
ment under which the respiratory function is laboring. 

The nostrils and nasal passages should always be examined also to 
ascertain the presence of mucous or purulent secretions, or of pseudo- 
membranous deposits, since these fluids or their inspissated products 
interfere more or less with the free passage of air through those canals. 

Of the Sleep. — Much useful information as to the state of health of 
infants and children may be obtained from a careful consideration of 
the various phenomena connected with their sleep. Of this we are 
fulh^ convinced from somewhat long and patient observation. We can- 
not ascertain, indeed, the nature of the disease under which the child 
may be laboring, but we can detect, with very great certainty, the ex- 
istence of a deviation from 'health. We know of few more certain 
means of fixing the period at which any attack of illness may have 
begun, than by inquiring at what time the child began to have restless 
or broken sleep, or insomnia. 

A perfectly healthy infant, within the month, who is suckled at an 
abundant and wholesome breast, will usually sleep twenty out of the 
twenty-four hours, waking to nurse every two or three hours during 
dayliglit, and twice or three times during the night. After the age of 
two or three months, the child is much more wakeful during the day, 
tho^agh it will still take a nap of two or three hours in the morning, 
and a shorter one in the afternoon, while it will sleep from early even- 
ing until the following morning, waking but once or twice to suck. 
Indeed, many perfectly healthy infants, of between three and six or 
seven months of age, sleep without waking from nine or ten o'clock in 
the evening until six the next morning. After the latter age the sleep 
is seldom so unbroken; the child begins to undergo the first consider- 
able trial to its health, dentition, and it is rendered thereby more or 
less ailing and irritable, and consequently restless and troublesome at 
night. 

Children who have passed through the epoch of dentition, and who 
are perfectly well, usually go to sleep soon after being put to bed, and 
never wake until the following morning. Not only so, but they sleep 
soundly and quietly, without being disturbed by slight sounds, and 
without tossing or turning much in their sleep. 

In healthful sleep the whole appearance of the child, its expression 
of countenance, its attitude, and its breathing, all declare a most per- 
fect and beautiful ease and tranquillity. Nothing can be more sugges- 
tive of the comfort and well-being that naturally attend upon health, 



24 INTRODUCTORY ESSAY. 

than the perfect composure and graceful postures exhibited by a hearty 
child during profound sleep. 

It needs, however, but a slight disturbance of the health of a child 
to break in upon its ordinarily calm and peaceful sleep, and to render 
this restless, fitful, interrupted by startings, cries, or dreams, or insuf- 
ficient. The most trifling irritations, as the pressure of a tooth against 
the gum, the presence in the digestive canal of a little imperfectly di- 
gested Ibod, or of one, two, or three lumbricoides, or the slightest fever 
from any cause, are sufficient to produce this effect, and hence it is that 
the character of the sleep will often become to a watchful practitioner 
the first sign of disorder held out by nature. 

The degree of disturbance of this function will vary with the nature 
and severity of the disturbing cause. When slight, the child will con- 
tinue to sleep throughout the ordinary period, but the sleep will be 
somewhat uneasy. The countenance will be disturbed. There will 
be contractions of the brow, and momentary w^orkings of the features, 
which express the perception of some unhealthful sensation. Often 
the child will toss and turn, and change its position more frequently 
than natural. Sometimes it will cry out, and appear distressed by some 
dream or painful sensation. When the cause of disturbance is more 
serious, the sleep is more broken, the child wakes often, and lies awake 
for a longer or shorter time, and it becomes very difficult to lull it to 
sleep again. Or it has painful dreams or nightmare, causing it to 
scream and struggle in sleep, and then to wake in the most violent af- 
fright. In severe instances it becomes almost sleepless. We have very 
often known teething children not to sleep more than half as much as 
in health, and to wear out, by the long continuance of this sleepless- 
ness, the patience and even the health of their attendants. In some 
instances they will no longer sleep in the bed or crib, and the nurse is 
obliged to get up and walk with them, or soothe them by the move- 
ment of a rocking-chair or cradle. In other cases, the derangement of 
the health is shown b}^ grinding of the teeth, and by the most violent 
tossing and tumbling about the bed. We have frequently seen a child 
lying with its head where its feet should be, or across' the bed, and 
with all the coverings thrown off, in spite of the most careful arrange- 
ment of the bedclothes. 

These various disturbances are therefore signs of some alteration in 
the health of the child. They do not lead to an appreciation of the 
precise nature of that alteration, but they are invaluable as affording 
indications of the existence of some morbid condition of the economy. 
Yery often, as above stated, they are the first symptoms of the ap- 
proach of some more or less serious sickness, and as such will often 
enable us to determine, with much precision, the moment of onset of 
the attack. 

The Cry. — Crying is one of the modes of expression of the child. 
Indeed, this, with the expression of the face, are, according to M. Bil- 
lard, the only means of expression with which nature has endowed the 
young infant. This is, however, scarcely correct, since we may also 



SIGXS FROM THE CRY. 25 

class amongst its means of expression the various spontaneous muscu- 
lar movements indicative of uneasiness, or of pain, or pleasure; the 
manner in which it drinks or sucks, whether eagerly, and with appe- 
tite, or languidly, or carelessly, or not at all; the enjoyment it receives 
from pleasant sounds ; and the evident delight it takes in regarding the 
light. Nevertheless, the cry and the expression of the countenance 
are the two means on which the phj^sician must chiefly rely for early 
information of the occurrence of sickness in the young infant. These 
are the trusty sentinels of nature. By them she first gives notice of 
the approach of danger, and then measures the amount of mischief 
that may have been done. 

The cry which a child utters during sleep, or even when awake, and 
when nothing has been done to excite or disturb it, is alwaj^s indicative 
of some uneasiness. If the cry be caused by pain, or by any considerable 
disturbance, it will be accompanied by certain contractions of the fea- 
tures and movements of the body and limbs, which will still more strik- 
ingly show that the pain, or other exciting cause, is of a serious nature. 
Violent and obstinate crying is almost always caused by severe pain, — 
such as the pain of earache. Indeed, obstinate and long-continued 
crjing, lasting for hours, is rarely met with except from one of two 
causes, earache or hunger. The cry of earache is often incessant and 
unappeasable, the pain being generall}^ constant and not paroxysmal, 
as are most other pains. It is to be silenced only by the application of 
remedies to the ear, or by the internal administration of opiates. We 
have known an infant, three months old, to scream with earache for 
two days and nights, with only short lulls of a few hours when brought 
under the influence of large doses of laudanum. As soon as the ear began 
to discharge, the cry ceased. We are constantly called to see infants and 
young children who have been crying most violently for hours, and who 
are thought to have colic, or to have hurt themselves, but who are, in 
fact, tortured with that most violent of all pains, earache. We have 
met with few instances in which such severe and constant crying has 
depended on other causes; for, though children scream violently and 
obstinately from hunger and thirst, they ma}^ always be quieted by the 
supply of either want, whilst in earache the infant generally refuses the 
breast, or takes it only for a few instants, and then lets go to resume 
his almost automatic scream. 

To show the difficulty of sometimes determining the cause of crying, 
we may mention that one of us once attended a nursing baby through 
a severe attack of bronchitis. Just as the child was recovering from the 
attack, it began to cry without any apparent cause. The cry was so con- 
stant, violent, and severe, that, feeling certain from the symptoms that it 
could not be from any dangerous cause, we concluded, by the method of 
exclusion, though, to be sure, there was neither tenderness of the ear to 
touch, redness or swelling of the meatus, nor discharge, that it must bo 
an earache. Hot applications and opiates applied to the ears did no good, 
and the constant scream set the mother iialf wild. At length, the grand- 
mother came in and said she thought the child wanted the breast. Sure, 



26 INTRODIQCTOKY ESSAY. 

enough, there was the trouble; the child lay at the breast almost con- 
tinuously for twenty-four hours, and earache, crying and all, vanished. 

In not a few instances we have thus known infants to cry very often 
in the day and night, and sometimes very obstinately, too, from hunger. 
In such cases the child is thought to have colic, and as it is not unfre- 
quently costive, it is dosed with cathartics, carminatives, and opiates; 
or^ it is being brought up partially or wholl}^ upon artificial diet, and as 
a consequence, has some disorder of the bowels, which is thought to re- 
quire other kinds of medicaments for its relief When the stools are 
natural in appearance, or merely costive, and when the child does not 
labor under flatulence, it is easy, by careful questioning of the mother, 
to discern whether she has milk enough, and by examination of the size 
and weight of the child, to judge whether growth and nutrition go on 
in their proper ratio; and if it be found that the mother is a poor nurse, 
and that the development of the child is slow and imperfect, we should 
at once direct an additional supply of nourishment, and the suspension 
of all mei-e drugs. We have often been surprised and delighted to find 
how soon, under the new treatment, the child becomes placid and com- 
fortable, how well and how long it sleeps, and at what a rapid rate it 
develops its form and size. So, when the circumstances above referred 
to coincide with a somewhat disordered state of the bowels, we should 
first choose for the child the diet most appropriate to its age and state 
of health, and then, if after inquirj^ it appears that the whole quan- 
tity taken in the twenty-four hours is below the proper standard, the 
amount allowed must be augmented. 

The crying occasioned by pain in the head, by the pain which accom- 
panies pneumonia or pleurisy, or that which is attendant upon abdom- 
inal inflammations, is never scarcely constant, though it ma}' be violent 
while it lasts. Pain in the head usually causes a sudden and sharp cry 
or shriek, which is over as soon almost as heard, and which has been 
called the hydrencephalie cry. The pain of pneumonia, which, it should 
be remarked, is not unfrequently absent, or so slight as not to be noticed, 
commonly occasions crying only during coughing, and for a short time 
after, and is accompanied bj' distortion or grimacing of the features. In 
pleurisy, again, the cry is also heard generallj^ at the moment of cough- 
ing, but it is produced also by the act of moving the child, and by pres- 
sure on the afi'ected side. It is commonly much louder, shriller, and in- 
dicative of greater suffering than in pneumonia, and in some cases that 
we have seen, has been very frequent and difficult to appease. 

The cry of intestinal pain may almost always be recognized by the 
fact that it takes place just before or after a stool, that it is accom- 
panied by wriggling and twisting movements of the trunk, and espe- 
cially of the pelvis, or, in very young infants, by its coincidence with 
more or less flatulence, which is revealed by a tympanitic condition of 
the abdomen, and by frequent regurgitations of gas. 

Children not unfrequently cry much and very obstinately from mere 
fretfulness and general distress or malaise. This kind of crying may be 
recognized by its peculiar tone, which is short, sharp, and irritable. It 



GENERAL APPEARANCE — DE VELOPxMENT , ETC. 27 

is a fret rather tlian a scream; it is occasioned by the least disturbance 
offered to the child bj^ the attempt to move it, to dress it, to attend to 
any of its wants, even to look at or notice it; it is moreover possible, 
generally, to still such a cry by soothing treatment^or bj^the endeavor 
to anmse the little thing with toys. 

Lastly, a child will sometimes attempt to cry, but is unable to utter 
any or only a very faint sound. This depends commonly upon some 
laryngeal impediment, but ma}" be also the result of pure exhaustion; 
there is not sufficient strength to sound a cry. 

The cry of the young child has been divided by M. Billard into the 
cry proper and the return; and inasmuch as these two portions of the 
cry are differently affected in different diseased conditions, it is impor- 
tant that we should beVware of their existence, and of the effects pro- 
duced upon their manifestations by disease. 

The cry proper is produced during the act of expiration, while the 
retui-n occurs during inspiration. The cry pi'oper is sonorous and pro- 
longed, the return is much shorter and sharper. The return is feeble 
in young infants, and becomes sti-onger as they advance in age. In 
different states of health, the mode of cr>ing will vary to a consider- 
al)le extent. The cry may exist alone, or in combination with the re- 
turn ; or again the return only may be heard, whilst the cry is from 
some cause suppressed. The distinction between the two portions of 
the cry may always be distinctly perceived in a child who is crying 
violently from any recent cause, whether ill-temper, fright, or pain, 
unless one or other has been suppressed by some morbid condition 
which interferes with the perfect performance of the vocal function. 
After a time, however, when the infant has become fatigued with its 
efforts, the cry proper ceases in part, and we have only the return, 
which is heard from time to time between the sobs. According to M. 
Yalleix, it is the return which becomes enfeebled and disappears first, 
whenever one portion only of the cry is heard. Towards the fatal termi- 
nation of all diseases, the return ceases more or less completely, and the 
cry assumes a peculiar moaning or murmuring character, which must 
be familiar to all who have been much in the sick-rooms of children. 

With a remark upon the condition of the lachrymal secretion in dis- 
ease, we shall conclude this division of the subject. 

The infant does not begin to secrete tears until towards the third or 
fourth month, and of course this function can furnish no sign previous 
to that time. After that period, however, the suppression of this se- 
cretion becomes, according to M. Trousseau, a valuable aid to progno- 
sis, as this suppression occurs generally in all dangerous acute diseases. 
The occurrence of this symptom in any acute case should be looked 
upon, therefore, as one of dangerous augury, while the continuance of 
the secretion, or its reappearance after it has been suppressed, is, on 
the contrary, a highly favorable omen. 

General Appearance OF the Child; Development; Embonpoint; 
State of the Skin, Etc. — While occupied in hearing the account of the 
sickness given by the mother or attendants, and even while asking 



28 INTRODUCTORY ESSAY. 

questions in regard to the present state of the patient, the physician 
may learn a great deal that is useful by an attentive observation of 
the general appearance of the child as it lies before him. He should 
study its size and development, its state of embonpoint or emaciation, 
its decubitus and gestures, the color, temperature, and dryness or hu- 
midit}' of the skin, and the presence of eruptions or swellings of any 
kind. Having remarked these various matters during the early part 
of the examination, he should proceed to inspect carefully the whole 
external surface by touch and sight, in order to acquire precise and ac- 
curate information upon these points. 

A child who has been health}^ from its birth ought to have attained 
a certain average size and development at a certain age. If it be much 
below the average size, if at three months it look like a new-born child, 
or at a \'ear old like one of six months, it is very clear that something 
has acted to determine such slow and insufficient growth, and it be- 
comes the business of the practitioner to discover what the impeding 
cause has been, ^ot only ought a child to have a certain size and 
stature, but it should also be possessed of a certain degree of embon- 
point. A perfectly healthy young child, one under four years of age, 
usually presents a much greater fulness and rotundity of the trunk and 
limbs than does the adult. Its tissues are firm and solid, its surface of 
a cool and pleasant temperature, its coloration of a clear and exquisite 
white, finely tempered with a faint rosy tint in a warm atmosphere, or 
slightly marbled with light bluish spots in a colder air. Few marks 
more certainly indicate a healthful temper of the constitution than the 
clear and exquisitely tinted pink color of the palmar and plantar sur- 
faces of the hands and feet of a young child. JS^othing, indeed, can be 
more beauiiful or perfect in shape or contour than the figure of a fine 
hearty young child; nothing more pleasing to the eye than its delicate 
but vivid coloring; and nothing more expressive of the fulness of health 
and vitality than its whole appearance. 

When, therefore, instead of these m:irks of a pure and active state 
of the health, we meet with stunted growth, emaciation, soft and flac- 
cid tissues, sallow and dingy tint of the cutaneous surface, pallid or 
bluish feet and hands, weak and listless movements, — how easy the 
conclusion that some jarring agent is at work to hinder and obstruct 
the machinery of life. 

In acute diseases emaciation takes place rapidly, but the tissues still 
retain some degree of elasticity and firmness. In chronic diseases the 
emaciation is of course slower, but it is more complete, so that, in some 
instances, the frame seems to consist merely of the bones wrapped 
round with a dark and unhealthy skin. The tissues beneath the skin, 
the cellular, adipose, and muscular, are in great part absorbed, and the 
skin falls into wrinkles and irregularities on the least movement of the 
child. In some cases of disease, and particularl}- in those of the abdo- 
men, the derm loses almost entirely its elasticity, so that when pinched 
into a fold by the fingers, it retains for some time the form that has 
been i^iven to it. 



I 



DECUBITUS — MUSCULAR MOVEMENTS. 29 

The decubitus and gestures of the child ought to be noticed. Healthy 
children are, when awake, almost always in motion. Those who have 
attained the habit of walking are tempted to active exercise by their 
various plays and amusements. Infants, though they sleep much more 
than older children, are also, when awake, constantly moving their 
limbs; they are seldom still. When asleep they rest quietly and com- 
fortably, generally upon the side, though often upon the back. How 
diifereut when the child is laboring under disease of any kind. The 
disposition to movement is gone; the older child insists upon lying on 
the lap, or in the cradle or bed, and the infant is to be soothed of its 
crying and fretfulness only by rocking and fondling in the arms. In- 
stead of the free and spontaneous movements of health, we now see 
only the sudden, impatient, and causeless tossing on the bed or lap, or 
the constant changing of position, with fretting or complaining, which 
constitute the agitation of sickness; or else the slow, languid and hesi- 
tating movements of weakness or prostration; or lastly, the stillness 
and immobility of stupor or of coma. 

There is nothing peculiar about the decubitus of pneumonia or bron- 
chitis except when there is severe dyspnoea, in which case the child, if 
old enough to select its own position, lies high upon the pillows, while 
those who are younger evidently prefer to rest on the lap of the nurse, 
with the trunk and head supported in her arms, and express by crying 
and agitation their discomfort and uneasiness when placed in the re- 
cumbent position on the lap, or in the cradle or crib. We have seen 
several young children affected with severe bronchitis or pneumonia, 
who have preferred to any other position that of being held in the 
nurse's arms, with the front of the chest placed against her chest, 
and the head hanging over her shoulder. When the dyspnoea is so 
severe as to produce, b}^ slow degrees, a partial asphyxia and conse- 
quent dultiess of perceptivity, the child becomes soporous or comatose, 
and lies usually upon the back, as in diseases attended with prostration 
of strength. 

In pleurisy and peritonitis the decubitus is usually dorsal, and the 
child dislikes to be moved or nursed often crying violentlj^ when touched 
or disturbed. 

In intestinal inflammations the young patient is usually excessively 
restless at first, and very fretful, unless the attack be grave and threat- 
ening, when it often lies still for a time from the prostration of strength 
which attends violent attacks, but becomes restless, turns and twists in 
the bed, cries out, and agitates the lower extremities at each evacuation 
of the bowels. 

In the early period of cerebral inflammation there is generally exces- 
sive restlessness, and great irritability of all the senses and temper, but 
as the case goes on, and passes into the stage of coma, the child becomes 
still and quiet, assuming very often the decubitus called by the French 
"en chien de fusil;" that is to say, on the side, w^ith the inferior extremi- 
ties strongly flexed, and the arms drawn close to, or crossed over the 
thorax. This position is especiall}^ characteristic of the latter stages of 
tubercular menino-itis. 



30 INTRODUCTORY ESSAY. 

Extreme restlessness, constant tossing upon the bed, or incessant 
changino- from the arras to the bed, or from bed to bed, is a very bad 
sign. We have observed it in several different affections; especially in 
obstinate pneumonia, in long-continued intestinal disorders, and in the 
secondary inflammations of measles and scarlet fever. 

Amongst the gestures most deserving of attention are the sudden 
starts, attended with cries, which indicate the occurrence of some pain- 
ful sensation, as that of colic, of stitch in the side in pneumonia and 
pleurisy, and sometimes of shooting pain in the head. The frequent 
carrying of the hand to the head, or to the ear, ought not to pass un- 
noticed, as this is often indicative of headache or earache. So also of 
the constant application of the hand to the mouth, or the introduction 
of the fingers into that cavity, which often occurs when the child is 
suffering the odontalgic pain of dentition. Nor should the physician 
ever neglect to observe any peculiar and especiall}^ any automatic 
movements of the limbs, and particularly of the fingers or toes. Nature 
often heralds the approach of a convulsive seizure by certain peculiar 
muscular movements. The thumbs are drawn into the palms of the 
hand, and the fingers clasped over them; or the toes are strongly bent 
tow^ards the sole of the foot, or rigidly extended; sometimes the fingers 
are for an instant convulsively extended upon the hand and drawn 
widely apart from each other; or lastlj^ the muscular movements, in- 
stead of being easy, stead}-, and natural, are badlj^ co-ordinated; they 
are irregular, uncertain, and tremulous. This latter character, tremu- 
lousness and uncertainty, we have often noticed. 

The occurrence of paralysis will often be unperceived for some length 
of time by an inattentive observer. It is to be discovered by the failure 
of the child to move one limb, whilst the others are more or less agi- 
tated, or b}' taking hold of the limb, and comparing the total want of 
resistance in it, with a certain stiffness and opposition to movement 
almost invariably present in the healthful condition. 

The state of the cutaneous surface is always important, and ought to 
be carefully and systematically examined. The points most requiring 
to be noted are its temperature, dryness or moisture, coloration, and the 
presence of eruptions or swellings. By the temperature, and dryness 
or moisture, taken in connection with the rate of circulation, we must 
judge as to the existence of lever. The inferences to be drawn from the 
condition of the surface in these respects are the same in children as in 
adults, and they need therefore no particular consideration in this place. 

The coloration of the skin, on the contrary, owing to its great sus- 
ceptibility to change in certain affections, becomes, in the diseases of 
early life, of Yevy considerable importance in diagnosis, and deserves 
therefore some special remarks. 

The physician should be aware, in the first place, that the color of a 
new-born infant is some shade of red, varying from a deep brick-red 
tint, to one of a much lighter hue. The red appearance fades away 
usually in about four or five days, and leaves the surface of a yellowish- 
white, or in some instances of a decidedly yellow color. The yellow 



ALTERATIONS OF COLOR. 31 

color is sometimes so marked as to impose very readily upon an inex- 
perienced person the idea that it must depend on an affection of the 
liver, or, in other words, that it constitutes a true jaundice. In a very 
large majority of cases, however, the conjunctiva retains its natural 
white tint, the digestive functions go on with perfect regularity, there 
is no fever, and indeed no marks of decided disorder of the health, so 
that the icterode hue cannot depend, under these circumstances, on any 
serious lesion of the liver or its appendages, and it is manifestly wrong 
to regard the case as one of disease, or as requiring any treatment. 

Besides the yellow color just described, the cutaneous surface in chil- 
dren, and particularly in those under three or four years of age, very 
otten exhibits different shades of a bluish color, which need some atten- 
tion. When the whole skin assumes a decidedl}^ blue tint, the case is 
one of cj'anosis or morbus coeruleus, depending on some malformation 
or disease of the heart or lunffs. In severe cases of this kind, the blue 
color deepens into a purple or even blackish hue. If this appearance 
last more than a very few days, there can be little doubt that it depends 
on some malformation or disease of the heart. 

It is quite common to observe in new-born and very young infants, a 
bluish tint of the hands and feet, and of the parts around the mouth, 
whilst the rest of the body is pale. These appearances depend usually 
on some obstruction to the pulmonary circulation, as that caused by 
atelectasis pulmonuni, bronchitis, or pneumonia, and they increase, 
diminish, or disappear, according to the course of the causative malady. 
In older children, the blue color of the skin is rarely of any consider- 
able intensity, unless the condition has existed from birth, or soon after; 
but it is not at all uncommon to meet with faint, but quite perceptible 
shades of ihat color, depending on the asphyxiated state which occurs 
in croup, capillary bronchitis, pneumonia, and sometimes in laryngismus 
stridulus. It is hardly necessary to add, that a very slight blueness of the 
fingers and toes is sometimes observed in the cold stage of intermittents. 

Occasionally we meet with an excessive harshness, aridity, and scur- 
viness, or with a wrinkled appearance of the skin, especially upon the ab- 
domen and thorax. This symptom, when strongly marked, is usually 
attended with enlargement of the superficial veins of that part, and is 
then very sti'iking even to a careless observer. It accompanies very 
generally the abdominal tuberculosis of children, and should not pass 
unobserved. Though generally indicative of tubercular peritonitis, or 
of tuberculosis of the mesenteric glands, it is not always so, since in a 
case that occurred to one of us, and in which it w^as perfectl}^ well 
marked, a post-mortem examination showed it to have been caused by 
a chronic peritonitis, resulting from inflammation and suppuration of 
the mesenteric glands entirely independent of tubercular disease. The 
peritonitis had given rise to extensive adhesions amongst the intestines, 
and the pus had found its way by a toi'tuous sinus between the intes- 
tines into the vagina, through which it was discharged externall}'. 

There is one other alteration in the color of the skin which is deserv- 
ing of notice in a practical point of view. It is an excessive pallor, oc- 



32 INTRODUCTORY ESSAY. 

earring sometimes in diseases which obstruct the respiratory function. 
We have been most strucli with it in the capillary bronchitis, or suffo- 
cative catarrh, of 3'oung children, and in membranous croup. The whole 
surface assumes a dead white hue, which seems to depend on a total want 
of blood in the cutaneous capillaries. The nose is white, the ears become 
white and diaphanous, and the only relief the eye meets with in gazing 
upon what seems an almost alabaster countenance, is the still pink or 
bluish lips, the dark e^^ebrows and eyes, and perhaps a somewhat leaden 
tint of the circumference of the mouth and of the forehead. In strongly 
marked cases the whole surface, even of the fingers and toes, exhibits 
this white or blanched appearance. When this condition has lasted for 
several hours, or a day or two, the hands and feet sometimes assume 
a bluish look, which may last until death occurs, or until the attack ap- 
proaches a favorable termination. This condition of the surface, when 
occurring in cases attended with obstruction of the respiratory func- 
tion, has alwaj^s appeared to us an indication of imminent danger to 
the patient; and, indeed, when it lasts more than one or two days, it 
has very generally proved the harbinger of death. 

The clinical examination of the cutaneous surface cannot be considered 
complete until it has been made with reference to the presence of erup- 
tions, of swellings from oedema, of inflammation, tumors, and, lastly, of 
diseases of the joints. The inquiry in i-egard to the presence of erup- 
tions is a very important one, from the fact that children are particularly 
liable to attacks of the exanthematous and other eruptive affections. 
Many attacks of sickness, beginning with violent fever and other seri- 
ous symptoms, which would otherwise remain entirely obscure or unex- 
plained, until a much later period from the onset, may be accounted for 
at an early period by a minute examination of the skin. So, in the latter 
stages of long and debilitating maladies, in the disorders which follow 
scarlatina, and in cardiac and hepatic diseases, a proper inspection of 
the surface will reveal oedematous effusions that might, if this search 
were neglected or carelessly prosecuted, remain undiscovered. The 
same remarks will apply to inflammations of the articular cavities, to 
the swelling of the joints produced by rheumatism, and to some obscure 
suppurative inflammations in the limbs of children. A most instructive 
example of the necessity of this close examination, occurred some years 
ago in the practice of one of us. A healthy male infant, five weeks of 
age, was seized suddenly with most violent fever, the reaction being 
not unlike in character that of acute rheumatic fever. The only visible 
disturbance of the health, to explain this violent attack, was a certain 
amount of digestive derangement, and for this the patient was treated. 
After three days of most severe illness, with strong tendency to con- 
vulsion, and with some stifl'ening of the lower jaw, we were asked to 
look at the right thigh. It was largely swelled, especially in its lower 
half; it was hard to the touch, and the skin over the outside of the limb, 
just above the knee, had assumed an inflammatory redness. It was 
clear that the child had been attacked with an acute inflammation of 
the deep tissues of the thigh, and that this was now approaching the 



PULSE. 33 

surface and becoming visible. Careful inquiry now brought to light 
the fact that the baby, all through the sickness, had cried severely, as 
though in sharp pain, whenever it was moved, and especially when its 
napkins were changed. The distress observed when the napkins were 
being changed, had been ascribed to some smarting from the urine. 
Had the surface of the child been more carefully examined at an early 
period, the swelling of the thigh, and the pain on motion, might, no 
doubt, have been detected then, and the intense febrile reaction, with 
the nervous symptoms, which were thought too great for simple func- 
tional disorder of the digestive functions, -would at once have been ex- 
plained. 

It is clear, therefore, that in infants and in children under six or even 
eight years of age, the physician must depend, in great measure, for in- 
formation as to the nature of the case, on his own unassisted explora- 
tions; and, knowing this, he should leave nothing neglected that may 
aid him to gauge with accuracy the state of health of the individual 
before him. He should cultivate a habit of minute, systematic, and 
patient investigation, since, by accustoming himself to such a method 
in his daily walks, he will assuredly attain, in the end, a tact and sa- 
gacity that will not often be at fault. 

Tbe Pulse. — The pulse of the child, in order to be judged of to any 
real advantage, must be examined during the state of quiet, and, if pos- 
sible, it should be felt whilst the child is either asleep or dozing. During 
the wakiiig state a young infant is in such constant motion, that it is 
ver}^ difficult to perceive the pulsations of the radial artery, and impos- 
sible to judge of their force or volume, in consequence of the rising and 
falling of the flexor tendons of the forearm, and because, also, of the 
natural softness and delicacy of the pulse at that age. In older chil- 
dren, the moral disturbance occasioned by the visit of the physician in 
most instances, and the irritability and nervousness accompanj^ing the 
sickness, will either cause the patient to resist the attempt to touch the 
arm, or else j)roduce so great an effect upon the rate and force of the 
circulation, as to render very uncertain and unsatisfactory any conclu- 
sions to be drawn from the examination. If possible, therefore, the 
circulation should be examined during sleep. If this be impracticable, 
the child ought, when still nursing, to be put to the breast, or, when 
weaned, it ought to be quieted by soothing treatment, by toys, or by 
the promise of a toy. 

It is essential that we should know what is the average of the healthy 
pulsations of the child, in order to obtain a standard of comparison by 
which to judge of any departure from that average in disease. Observ- 
ers have varied not a little in the results at which they have arrived by 
their examinations upon this point. By selecting those, however, which 
appear to have been made with the greatest care, and under the most 
favorable circumstances, we shall, doubtless, obtain an average entirely 
worthy of confidence. It will be necessary, also, to obtain averages for 
different periods of childhood, since the rate of the circulation varies to 
a very great extent at different ages. We shall, therefore, give the rate 



34 INTRODUCTORY ESSAY. 

of the circulation for new-born children (one to ten days old), for the 
period from four months to six years, for that from six to nine years, and 
for those from nine to twelve, and from twelve to fifteen 3'ears of age. 

The average rate of the circulation in verj^ young infants, is from one 
hundred and one to one hundred and two in the minute, the former being 
the result obtained by M. Billard in children from one to ten daj'S old, 
as nearly as it can be gained from his statements, and the latter the one 
obtained b}^ M. Eoger, in infimts from one to seven days old (De la 
Temperature chez les Enfants^ Paris, 1844). The physician ought, how- 
ever, to be aware of the fact that, though the above is the average rate 
of the circulation at the age mentioned, the pulse may range very much 
above or below that average, without necessarily indicating a morbid 
state of the health. Thus, though the average frequency in fort}^ chil- 
dren, from one to ten days old, observed by M. Billard, was one hun- 
dred and one, it was less than eighty in eighteen, whilst in fourteen it 
was between one hundred and one hundred and twenty-five, and in six 
between one hundred and thirty and one hundred and eight}'. All 
these children, he assures us, presented every mark of good health. 

The average frequency of the pulse during the first year may be stated 
at about one hundred and fifteen ; at least such is the result obtained 
by us from an examination of seven observations by M. Roger of chil- 
dren from four to nine months old. This result, it will be observed, 
shows that the pulse is not so frequent during the first few days after 
birth, as it becomes at a somewhat later period, which, moreover, agrees 
with a previous statement to the same effect made by M. Yalleix. This 
latter author is of the opinion that at seven months of age the pulse 
is much more frequent than some days after birth, and that it after- 
wards falls gradually as the child advances in years. 

We are not acquainted with any observations upon the rate of the 
circulation during the second year of life, except those of M. Trous- 
seau, who, according to M. Bouchut {Manuel Prat, des iVah des JSouv.- 
iVes, p. 133, Paris, 1845), gives as the average between one year and 
twenty-one months, one hundred and eighteen. 

M. Becquerel (Traite Theorique et Prat, des Mai. des PJnfants, Paris, 
1842), gives us the result of his. observations upon thirty children, be- 
tween two aud six years of age, during sleep and in the waking state. 
During sleep the average was seventy-six; in the waking state it was 
ninety-two. 

Between six and nine years of age, the same observer found the 
average during sleep to be from seventy-three to seventy-four, whilst 
in the waking state it was ninety. Between nine and twelve years, 
the average was, during sleep, seventy-two, in the w^aking state, 
eighty. Between twelve and fifteen j-ears the rate was seventy whilst 
the children were asleep, and seventy-two when awake. Roger gives 
seventy-seven as the average between six and fourteen years. 

One very striking fact attracts our attention in the above statements: 
the much greater difference between the rate of the circulation during 
sleep and during the waking state, in very young children, than in those 



PULSE. 35 

who are somewhat older. Thus, whilst there is a difference of seven- 
teen pulsations in the minute, in the rate of the circulation during sleep 
and in those who are awake, between the ages of two and six years, 
the difference under the two conditions mentioned, amounts to only 
two pulsations in the minute in children that have reached the age of 
between twelve and fifteen years. 

The circuhition is somewhat more rapid in girls than boys. This 
difference should be borne in mind, but as it amounts to only about five 
beats in the minute, it is insufficient to be of any very decided value in 
diagnosis or prognosis. 

After these specifications as to the rate of the circulation in children, 
we shall pass on to some general remarks upon the method of the ex- 
amination of the pulse, and upon some other of its important char- 
acters. 

M. Bouchut (loc. cit., p. 129) remarks that in infants at the breast 
" the palpation of the pulse is almost impossible. It may be counted, 
but its force, feebleness, size and hardness, can scarcely be appreciated ; 
the intermittent character is the only phenomenon upon which no 
doubt need rest; it is, moreover, the only one of any value." These 
opinions of M. Bouchut, though true in some degree, are much too 
strongly stated, for we are quite sure that it is very easy to detect 
great differences in the force, size, and tension of the pulse of the same 
child in health and in disease, and of different children laboring under 
different di-seased conditions. These differences can be detected by 
careful observation from a very early age, and after two months may 
be readily recognized, when the variation from the state of health is 
at all considerable. 

The intermittence of the pulse above alluded to, should rather be ex- 
pressed by the word irregularity, since the pulse is not properly inter- 
mittent, but merel}^ irregular in its rhythm. This is quite a common 
feature in the pulse of children, and, be it noted, is much more fre- 
quently met with during sleep than in the waking state. M. Becquerel 
met with irregularity of the pulse in twenty-four of one hundred and 
fifty children examined during the waking state, and in fifty-five of one 
hundred and fifty during sleep. It is clear, therefore, that mere irregu- 
larity of the circulation, independently of other symptoms, is not a sign 
of disease, since it was present in one-sixth of those awake, and in a 
little more than a third of those asleep. It should be observed, too, 
that the greatest irregularity exists when the pulse is lowest (in sleep). 
The chief practical bearing of this fact is that we should be careful not 
to lay too much stress upon the slowness and irregularity of the pulse, 
as signs of tubercular disease of the cerebral meninges, unless they are 
observed during the waking state, and in connection with other symp- 
toms; particularly with vomiting, constipation, and severe headache. 

Another very important characteristic of the circulation of the child, 
is its extreme irritability, which causes its rate to vary to an extraor- 
dinary degree, even in perfect health. This is the more marked in pro- 
portion as the child is younger. The slightest disturbance, whether 



36 INTRODUCTORY ESSAY. 

moral or phj^sical, will cause the pulse to rise in a young child from 
one hundred or one hundred and fifteen, to one hundred and twenty, 
one hundred and thirty, or even one hundred and fifty. From this cir- 
cumstance may be drawn the inference also, that the pulse should al- 
ways be examined, as before stated, during sleep, or during profound 
quiet. 

There is still another reason which makes it necessary to touch the 
pulse during sleep or profound quiet. This is, that when the child is 
agitated, it becomes literally impossible, in consequence of the contrac- 
tions of the flexor tendons of the arm, and of the movements of prona- 
tion and supination, to judge with accuracy the various qualities of the 
arterial action. 

Examination of the Heart. — The examination of the heart by aus- 
cultation and percussion ought, and, to be of essential aid in diagnosis, 
must be performed while the child is still and quiet. It is best made 
during sleep, especially in infants; when this is impossible, it can be 
performed with great advantage during the state of quiet that follows 
nursing, or during that which may often be procured by soothing man- 
agement, or by taking advantage of the fondness that infants show for 
a strong light, the view of which will generally suffice to occupy and 
keep them still. 

The sounds of the heart present the same general characters in the 
child as in the adult. They are, of course, more feeble and more rajDid ; 
conditions which make it difficult, in the young infant, to perceive and 
appreciate any minute change from the healthful sounds. After the 
age of one and two years, however^ when the circulation has become 
slower and more steady, the signs j^ielded by the physical examination 
of the heart become much more valuable and positive; so much so, in- 
deed, as to yield results almost as important as in the adult. The first 
sound is almost always duller than the second. They succeed each 
other commonly with perfect regularity, and have the same interval 
between each in the same child. The cardiac sounds are readily heard 
by placing the ear over the prsecordial region. The extent of surface 
over which they may be heard will depend on several conditions: par- 
ticularly the state of quiet or agitation of the child, the presence or 
absence of fever, the state of the lung as to its consistence (constituting 
it a better or a worse conducting medium of sounds), and the condition 
of the heart itself as to health or disease. 

In a healthy child, who is undisturbed by any cause of irritation, and 
particularly in one sleeping, the sounds are distinctly audible over the 
whole precordial region and under the left clavicle. In many subjects 
they can be heard over the whole front of the thorax, but become, of 
course, feebler in proportion as we recede from the praecordial region. 
Usually they are heard quite as distinctly under the right clavicle as 
over the nipple of that side, in consequence, no doubt, of their trans- 
mission in an upward direction by the aorta. They are never heard 
over the posterior walls of the chest in children in perfect health, and 
whose circulation is entirely undisturbed. In those who are awake 



THERMOMETRIC OBSERVATIONS IN CHILDREN. 37 

and agitated, and in those who have been making severe muscular 
exertions, the cardiac sounds are very loudly audible over the whole 
front of the thorax, and even through to the back of the chest. 

When the lungs are indurated b}" inflammation, as in pneumonia, 
they transmit with great distinctness, from having become better con- 
ducting media, the cardiac sounds to the back. This circumstance 
sometimes becomes a valuable aid in the diagnosis of pneumonia. We 
have been enabled to satisfy ourselves of the existence of pneumonia in 
the lower lobe of the right lung, in a doubtful case, from the fact that 
the sounds of the heart were much more clear and distinct over the 
right inferior, than over the left inferior dorsal region. 

The precordial region is decidedly less sonorous on percussion than 
the parts of the thorax directly over the lungs. This diminution of 
sound is distinct enough to be evident to any ordinary ear, but it rarely 
amounts to absolute flatness. The region exhibiting this dulness of 
sound is the same in position as in the older person. It occupies the 
space corresponding to the cartilages of the fifth, sixth, and seventh 
ribs, and is situated, therefore, between the left nipple and the left edge 
of the sternum. Its measurements, as given by MM. Rilliet and Bar- 
thez, are one and a half to three inches in a transverse, by one and a 
half to two and a half in a vertical direction. The region of dulness is 
described by those observers as being represented by a circle or ellipse, 
the transverse diameter of which extends from the nipple to the sternum, 
or more rarely, towards the xiphoid cartilage. In children over six 
years old, the nipple sometimes lies above the middle line of this space. 

Thermometric Observations in Children. — As an indication of the 
intensity and character of the disease in febrile attacks, we have seen 
that the frequency of the pulse is little to be depended on. Dr. Foi'ster 
(Jour.f. Kind., July and August, 1862, in New Syd. Soc. Year-Book, 1862, 
p. 413), who has made an extensive series of observations upon this 
subject, asserts that variations in the temperature of the body offer far 
more certain indications. The instrument used was a Reaumur's ther- 
mometer, eight and a half inches long, in which slight variations are 
easily appreciable. The bulb was placed in the axilla. 

The results given are those of observations upon healthy children, 
during the first few days of life. 

A constant lowering of the temperature of the body takes place after 
birth, which reaches its maximum, 28.97° R., on an average within the 
first two hours after birth. 

Hours after Birth, Average Temp. (R.) Minimum Temp (R.) 

A— 2, 28.97 28.2 

2—6, 29.12 28.1 

6—10, 29.49 28.7 

10—15, 29.53 29 

15—20, 29.31 28.8 

20—25, 30.04 29.7 

25—30, 29.9 29.7 

30—36, 30.07 29.7 

36—42, 30.04 29.4 

42—48, 29.86 29.3 



38 



INTRODUCTORY ESSAY. 



A subsequent elevation always occurs. The average time at which 
the highest temperature was observed, was from thirty to thirty-six 
hours after birth, at which time the average was 30.07° E. : maximum 
30.4° R., minimum 29.7° E. 

This elevation was noticed equally when the infant had and had not 
taken food. 

During the first nine days of life, the temperature was observed as 
follows : 



Days. 


Maximum (R.) 


Minimum (R.) 


Average (R.) No 


. of Obsei 


1 -U, . . 


. 30.4 


29.7 


30.01 


22 


H-2, . . 


. 30.5 


29.3 


29.93 


16 


2 —2^, . 


. 30.4 


29.3 


29 87 


28 


2^—3, . 


. 30.3 


29.2 


29.74 


16 


3 -3|, . . . 


. 30.3 


293 


29.76 


27 


3^-4, . 


. 30.2 


29.0 


29.68 


17 


4 -4h . . . 


. 30.4 


29.2 


29.68 


25 


4^-5, . 


. 30.3 


29.2 


29.72 


18 


5 -oh . . . 


. 30.4 


29.2 


29.82 


23 


5|-6, . . 


. 30.5 


29.3 


29.81 


16 


6 -6J, . . 


. 30 6 


29.4 


29.83 


23 


64-7, . . 


. 30.3 


29.1 


29.75 


17 


7 -74, . . 


. 30.4 


29.3 


29.82 


22 


7J-8, . . 


. .30 4 


29.0 


29.72 


11 


8-8J, . . 


. 30 


29.4 


29.70 


8 


8^-9, . . 


. 29.9 


29.6 


29.75 


2 



We thus see that from the thirtieth to the thirty-sixth hour after 
birth the highest temperature is observed. Then a fall takes place, 
which reaches its maximlim at four days after birth (average maximum 
29.68° R.). Again, between the fifth and eighth days, a new elevation 
of temperature occurs; but this new elevation is less in degree than 
that previouiily noted. The average maximum was 29.83° R. Some 
differences were found in the results, according as the children were 
large and heavy, or the reverse. Large and well-developed children 
had a slightly higher temperature than those less robust. 

Thus the average temperature in the early part of the day was, in 
children weighing eight pounds and upwards, 29.84° R.; but, in children 
weighing less than this, the average was 29.65° E. The evening obser- 
vations, again, gave an average for the heavy children of 29.94°; for 
the others, of 29.77° E. Eespecting the temperature at different times 
of the day, observations showed that, from the second to the ninth day, 
there was an average elevation of temperature, from morning to even- 
ing, amounting to .11° E.: the average morning temperature being 
29.75° E. ; the average evening temperature, 29.86° E. 

This interesting subject has been further examined in regard to older 
children, by Mr. Finlayson {Proc. of Manchester Med. Soc, in Brit. Med. 
Jour., Jan. 16, 1869, p. 59). 

His results are based on two hundred and eighty-one observations on 
eighteen different children, of ages varying from twenty months to ten 
and a half years, and are as follows : 



RESPIRATION, ITS RATE, ETC. 39 

1. The daily range of temperature is greater in the healthy child than 
that recorded in healthy adults — amounting to 2° F. 

2. There is invariably a fall of temperature in the evening, amounting 
to 1, 2, or 3 degrees. 

3. This fall may take place before sleep begins. 

4. The greatest fall is usually between 7 and 9 p.m. (at least under the 
conditions of life in hospital). 

5. The minimum temperature is usually observed at or before 2 a.m. 

6. Between 2 and 4 a.m. the temperature usually begins to rise, such 
rise being independent of food being taken. 

7. The fluctuations between breakfast and tea-time, are usually trifling 
in amount. 

8. There seems to be no ver^- definite relationship between the fre- 
quency of the pulse and respirations, and the amount of temperature; 
the former being subject to many disturbing influences. 

Eespiration; its Kate and General Characters. — The respiration, 
like the pulse, to be examined with an}^ advantage to the explorer, must 
be investigated whilst the child is still and quiet. In the young infant 
it should be done during sleep, as it is only then that we can find the 
breathing uninfluenced by disturbing causes other than those connected 
with deranged health. In the older child, the play of whose functions 
is more steady and regular, and less readily jarred by ti'ivial causes, 
this part of the clinical exploration may be made during the waking 
state; but, still, it must be done whilst the patient is quiet and tranquil, 
else the results obtained will necessarily be less certain and reliable 
than under the opposite state of things. 

The respiration ought always to be counted by the watch, if possible, 
especially by the young practitioner. This is the only mode in which 
a perfect]}^ accurate idea of the frequency of the respiration is to be ob- 
tained. It sometimes happens that a greatly increased rate of the 
breathing w^ill pass unnoticed by the physician, from the fact that it 
continues to be regular and without effort. We have known children 
to bi'eathe eighty times in the minute, without presenting any appear- 
ance of labor or effort in the act ; without cough, and without the least 
wheezing or sound to be heard at a short distance from the patient. 
Under these circumstances, the great rapidity of the respiration might 
very well pass unnoticed, especially by inexperienced practitioners ; 
and, be it remarked, this would be particularly apt to happen were the 
attention of the physician addressed to some other part of the economy 
than the thorax, as the seat of the sickness. For instance, in latent 
pneumonia, when this simulates meningitis, or when it js conjoined 
wnth gastro-intestinal symptoms, the failure to note a greatly increased 
rate of the breathing might very well occur. In many cases of second- 
ary pneumonia, it might also take place. In children, w^ho have been 
long sick with diseases that debilitate and impoverish the health, a 
sudden aggravation of the symptoms dependent on collapse of the 
lung, might be misunderstood and falsely explained, for the want of 
this precaution. It is therefore a good and useful rule, for the young 



40 INTRODUCTORY ESSAY. 

practitioTier alwa^^s to count the respiration, when he has to do with 
a case presenting the least obscurity of diagnosis, since this simple 
habit may guide him to the real seat of disease, which else he might 
mistake. 

The rate of the respiration in children is very different at different 
ages, a circumstance that should always be recollected in the examina- 
tion of their diseases. The average frequency of the breathing in new- 
born children and during the first week of life, is thirty-nine, according 
to M. Roger. It may rise, however, upon very slight disturbances, to 
fifty, sixty, or even eighty, while it is not at all unusual to find it at 
twentj^-five or thirty in perfectly healthy infants during sleep. Between 
the ages of two months and two years the average is about thirty-five. 
Between two and six years, the average is eighteen during sleep and 
twenty-three during the waking state ; from six to twelve years, the 
average during sleep is eighteen, and in the waking state twenty-three; 
from twelve to fifteen years, it is eighteen in the former, and in the 
latter twenty. It will be observed, therefore, that after the age of two 
years, the rate of the respiration is nearly the same throughout the 
remainder of the period of childhood; it changes so little, indeed, that 
the same average will answer for all practical purposes throughout that 
pei'iod. 

The other characters of the respiration require some attention on 
the part of the practitioner. In the first place, the diaphragm plays a 
more important part in the process in the child than in the adult. In 
the young infant, indeed, the function is carried on almost wholly by 
the action of that muscle, so that the respiration is correctly described 
by the technical term of abdominal. The walls of the chest are almost 
motionless. On this account the rate and characters of the breathing 
can be best studied in young children, by examining the abdomen, the 
movements of which being strong and marked, are much more easily 
seized by the eye than are those of the thorax. 

During perfect quiescence, and especially during sleep, the breathing 
of a young child is soft, regular, though less so than in the adult, and 
perfectly noiseless; it is necessary to place the ear close to the face or 
chest of the child, and to listen attentively, in order to hear it. In the 
young child, and especially the young infant, the breathing is, in the 
waking state, very different from that of the adult. It is short, irregu- 
lar, uneven, and marked by occasional pauses, followed by a hurry and 
precipitation of the movements. These peculiarities in the respiration 
of the infant appear to depend on the weakness and imperfect action of 
the muscular apparatus at that early age, which causes the various 
movements of the body to be hesitating and uncertain, and without that 
steadiness and evenness which are characteristic of matured strength. 
After the age of two years, these irregular and tumultuous move- 
ments cease, and the breathing becomes more regular and even, like 
that of adults. 

In the inflammatory affections of the lungs, — pneumonia, bronchitis, 
and pleurisy, — the respiration is almost invariably accelerated. In ex- 



SIGNS FROM THE RESPIRATION. 41 

tensive pneumonia, and in capillary bronchitis, it becomes very rapid, 
rising to eighty or one hundred in the minute. In pleurisy and simple 
ordinary bronchitis, it seldom becomes so frequent, not exceeding, usu- 
allj', forty or fifty. In severe pneumonia, the rhythm of the movement 
sometimes becomes inverted: the pause occurs at the termination of 
the inspiration instead of the expiration. The patient makes first a 
violent and labored expiration, bringing into a kind of convulsive 
action all the expiratory muscles of respiration ; instantly after the 
expiration follows a rapid and full inspiration ; then occurs a momen- 
tary pause, and again the respiratory act begins with the labored ex- 
piratory effort. This kind of respiration is a very unfavorable symptom, 
as it is indicative of a most dangerous oppression. It is particularly 
apt to occur in infants, and very young children. It has been called 
expiratory respiration. 

The respiration, though almost invariably accelerated in pulmonary 
inflammations, sometimes retains its normal rate, or even falls below 
that rate. This occurs, we believe, only under one condition of things: 
when the forces of the constitution have been sapped by previous dis- 
ease, or exhaused by the long continuance of the thoracic inflammation. 
It is therefore met with in cases of secondary inflammations, and in 
those of the chronic form. 

The respiration is very much increased in frequency as a general rule 
in Atelectasis Pulmonum, or collapse of the lungs. When, therefore, a 
young child who has been exposed to the causes of this disease (feeble- 
ness at birth, exhausting disease, or debilitating hygienic conditions), 
is suddenly seized with hurried respiration, slight cough, paleness or 
blueness, with coldness of the cutaneous surface, and in whom there 
are but few and unimportant physical signs of pulmonary disease, there 
is very good reason for supposing that some portion or portions of the 
lungs have become collapsed, or, in other words, have ceased to admit 
air. 

The respiration often lends some assistance in the diagnosis of cere- 
bral affections. In acute meningitis, accompanied by violent febrile re- 
action, it is more frequent than natural, but often irregular. When the 
early stage passes into the stage of coma, the breathing becomes slow 
and irregular. In tubercular meningitis it is seldom increased in fre- 
quency except for a day or two before death, whilst in the middle period 
of the disorder, it is either continued at its normal rate, or becomes 
slower. During that period, also, it is almost always extrerael}^ irreg- 
ular, and is interrupted by long and mournful sighs, which, to the ear of 
the experienced physician, who hears in them the almost certain prog- 
nostic of approaching death, have an inexpressibly touching sound, 
increased tenfold by the consciousness of his utter inability to control 
the fatal tendency of the malady. 

There is a peculiarity of the respiration which occurs in collapse of 
the lung, and also in cases of membranous croup, which ought not to be 
passed by unnoticed. It is, that, during the inspiratory effort, the ribs 
move inwards and backwards towards the mesial line of the trunk, in- 



42 INTRODUCTORY ESSAY. 

Stead of outwards as in normal respiration ; and at the same time there 
may be recession of the lower part of the sternum, so that a more or less 
deep sulcus is produced around the baseof tlie thorax. This peculiarity 
is readily explained, as shown by Rees and Jenner, by reference to the 
normal relation which exists between the current of inspired air, the 
expansion of the lungs, the descent of the diaphragm, and the firmness 
and resistance of the thoracic walls. If this relation be disturbed in 
any way, the phenomena we are now considering may be produced. 
Thus if the diaphragm contract suddenl}^ and violentl}^, the lungs can- 
not expand with suflicient rapidity, and in order to prevent the occur- 
rence of a vacuum, the thoracic walls must yield to the external atmos- 
pheric pressure at their least resisting part, which is, under normal 
conditions, at the base of the chest. The same result must occur, also, 
when the diaphragm contracts with only normal force, but when the 
calibre of the lar^-nx is much narrowed, or again, when a consider- 
able portion of lung-tissue is collapsed. In the article on rickets, an 
affection in which the firmness of the chest-walls is much diminished, 
a full account will be found of the masterly manner in which Jenner 
has applied the above principles to the explanation of the deformities 
of the thorax so characteristic of that disease. 

Auscultation and Percussion of the Lungs. — This portion of the 
examination of the sick child ought to be performed, if possible, whilst 
the patient is still and quiet. Unfortunately, however, it happens in a 
large majority of cases that the disturbance of position necessary to 
effect the exploration, and the presence of the physician, together with the 
irritability of nerves and temper occasioned by sickness, almost always 
cause more or less resistance on the part of the child, and produce violent 
screaming and struggling. In young infants we have to contend only 
against the instinctive resistance to anj^ phj'sical disturbance naturally 
attendant upon sickness and suffering. In older children, who have 
learned to distinguish between familiar and strange faces, and in whom 
the will has begun to act, there is added to the instinctive resistance 
of the infant an opposition of the most strenuous and annoying kind, 
founded upon the natural fear of a stranger, and upon a mental deter- 
mination not to be interfered with or incommoded by the movements 
and changes of position necessary for a careful examination. 

For these reasons, the physical exploration of the chest in young sub- 
jects is often to be accomplished only with great difficulty, and in the 
midst of the most violent screaming, struggling, and contention. It is 
clearly important to avoid these obstacles if possible. This can onlj^ be 
done by the employment, on the part of the attendants and physician, of 
the most soothing, gentle, and patient management; and in this way, let 
it be remarked, it can be done in a large majority of cases. The posses- 
sion by the physician of a quiet and yet decided manner, the power to 
interest and attract the child by entering with active sympathjMnto its 
little amusements and pursuits, the skill to engage its attention by the 
exhibition of some book or toy, or the mere influence he may exert to 
calm its terror or excited irritability, by a soothing voice and gentle 



EXAMINATION OF THE LUNGS. 43 

persuasion, will, in many instances, overcome any resistance offered to 
the examination by children over two years of age. Nevertheless, in 
very young children, and in not a few that are older, no gentle means 
whatever will overcome opposition. Here the exploration must be made 
in the midst of strno-o-les and cries, and though the results obtained will 
be less clear and positive than when the child is reasonable and obe- 
dient, a great deal of most valuable information can be acquired by a 
quick and dexterous practitioner. The percussion can be made in the 
short intervals between the cries, or even during their continuance, and 
by placing the ear close to the finger by which it is performed, the 
sounds elicited can be very well heard and judged. The auscultation is 
more uncertain; but, by watching intently the long and dee]) inspira- 
tions which immediately precede the violent cries, the presence or ab- 
sence of rales, and their characters, the degree of freedom with which 
the air enters the lung, and the existence or non-existence of bronchial 
respiration, can, after some experience, be ascertained and commented 
upon, so as to give considerable certainty to the diagnosis. 

The particular position in which to place the child, during the exami- 
nation, is of some importance. After the age of three and four years 
the position may be the same as that selected for the adult, if only the 
patient be reasonable and tractable. When, on the contrary, the child 
resists, it should be taken on the lap of the mother or nurse, or else held 
in the arms, with the head inclined over one shoulder, while its back is 
presented to the practitioner. Infants within the year may sometimes 
be examined whilst engaged in the act of sucking; but this is inconve- 
nient, both from the constrained position, and from the circumstance 
that the inspirations are short and imperfect during the act. The French 
authors recommend that the very young infant should be laid, with its 
face dowuAvards, across the hand of the pi-actitioner, who is then to ap- 
proach the back of the chest to his ear. We have found either one of 
the three following positions most convenient, as the case may be : the 
infant laid across the lap of the mother, with its face dow^nwards, and 
the head hanging a little over one knee; held in the arms, with the 
front of its body placed against the mother's chest, and the head lying 
over her shoulder; or, lastly, a favorite position of ours, placed in a 
sitting posture upon the lap, supported by one hand in front, and by 
the other holding the occipital portion of the head. 

Auscultation should always be performed before percussion, because 
the latter generally alarms or annoys the child, and occasions crying, 
which of course would interfere more or less with the auscultation, 
w^ere this performed after percussion. The auscultation should be 
made wnth the ear rather than the stethoscope, for the reason that 
the instrument terrifies the child, and also because it cannot, when the 
child resists and struggles, be kept in contact with the chest. More- 
over, the instrument is unnecessary except for the examination of the 
upper portions of the thorax in front, and it had better, therefore, be 
dispensed with. 

Percussion is best made in children by using a finger of the left hand 



44 INTRODUCTORY ESSAY. 

as the pleximeter, and b}^ striking with one finger of the right. One 
finger is quite sufficient to elicit all necessary sound in young subjects. 
The strokes should be light and distinct, consisting of short, quick, and 
gentle taps. 

To perform auscultation and percussion with success, the surface 
ought to be quite uncovered. The habit of examining the thorax 
through one or several thicknesses of clothing, which some persons 
fall into, is a most careless one, and cannot but lead to uncertain and 
erroneous results. 

As a general rule, it is sufficient, in young children, to examine the 
posterior portion of the thorax. Doubtless it is more accurate and 
artistieal to explore the w^hole chest, and this ought to be done in all 
obscure cases. But when the child is sick and suffering, when it is 
irritated and exasperated by the presence of a stranger, or by coercion, 
and still more, when it is weak and exhausted by long or violent ill- 
ness, it becomes of the greatest importance to shorten, as much as 
possible, the time occupied in the examination. For these reasons, it 
is well to be aware of the fact that, in nearly all inflammator}^ diseases 
of the lungs, the morbid changes affect first and most severely the pos- 
terior surfaces of those organs. This is thought to depend on the fact 
that the child passes so large a portion of its time in the recumbent 
position as to cause the fluids of the body to gravitate towards the de- 
pendent parts of the lungs, and thus to determine the beginnings of 
inflammatory action in that direction. Certain it is, be the explana- 
tion what it may, that it is rare to find the anterior surface of the lungs 
affected either with bronchitis, pneumonia, or pleurisy, the posterior 
surface remaining health}^ When, therefore, upon auscultation and 
percussion, no signs of disease are met with over the dorsum of the 
thorax, we may feel pretty well satisfied that the lungs are healthy. 
Nevertheless, in all doubtful cases, the examination ought to be ex- 
tended to the whole chest, in order to make what was, before this has 
been done, only a strong probability, a certainty. Whenever, also, it 
is important to ascertain the precise amount of disease in any serious 
or long-continued sickness, the front as well as the back part of the 
chest must be examined. 

The respiratory sounds are not of the same character precisely in the 
child as in the adult, and of this the physician ought to be aware. In 
children the vesicular murmur is stronger than in the adult, so that it 
assumes somewhat of a blowing or bronchial sound. It was in con- 
sequence of this peculiarity that Laennec gave it the name of puerile 
respiration, which, though a mark of health in early life, is, at the 
period of maturity, an indication of a morbid change in some portion 
of the pulmonar}^ parenchyma. It ought to be remarked, however, 
that in infants under two, and particularly in those under one year, 
the vesicular murmur is, in ordinary respiration, weaker than in adults; 
owing, no doubt, to the fact that the inspirations are short and imper- 
fect, not distending the lungs to their full capacity. When, however, 
from any cause, a sigh, a sudden disturbance, or the act of crying, a 



EXAMINATION OF THE LUNGS. 45 

full and complete inspiration takes place, so as to dilate thoroughly the 
pulmonary structure, the murmur becomes at once loud and strong, or, 
in other words, puerile^ as in older children. 

The murmurs of inspiration and expiration bear the same relation 
to each other as in the adult; the expiration being much shorter and 
feebler than the insj)iration, though, at the same time, it, like the in- 
spiration, is louder than in the adult. In some instances, however, 
and especially over the posterior, inferior, and lateral regions of the 
thorax, no sound whatever is heard during the accomplishment of the 
expiration. This absence of sound during expiration is the more apt 
to be met with in proportion as the child is younger. 

When a young child is made to breathe forcibly and rapidly, the res- 
piratory sounds assume certain characters, even in perfect health, 
which might mislead an inexperienced observer. The inspiration is 
short, loud, and hard, so as to assume somewhat of a blowing charac- 
ter, resembling not a little the sound of bronchial respiration. At the 
same time, the expiration becomes louder also, and longer, which two 
circumstances, rude or even blowing inspiration, with loud and some- 
what prolonged expiration, may very well deceive a young or careless 
practitioner. 

The respiration is most clear and characteristic over the anterior, 
lateral, and posterior inferior regions of the thorax. Over the origin 
of the larger bronchia, that is to say, in the interscapular region, the 
respiration is very strong, so as to resemble very closely bronchial 
blowing. Here, also, the expiration is often very marked; it is some- 
times heard as long, or even longer than the inspiration. Over the 
scapulas, the sound of respiration is always feebler than elsewhere, ex- 
cept in the prsecordial region, from the interposition of the scapulas 
and of thick muscles between the ear and the lung. 

Percussion y'lQXd^ a much louder and more sonorous sound in children 
over two years of age than in adults, — a circumstance always occurring 
coincidently with the presence of puerile respiration, and dependent 
on the fact that the function of respiration is, at that age, very active, 
and the lungs therefore filled to their utmost capacity with air. In in- 
fants under two years of age, the sonorousness varies to a considerable 
extent in the same child. When the respiration is, as it usually is, 
gentle and easy, the inspirations being rather feeble and incomplete, 
the amount of air contained in the lungs will be somewhat deficient in 
comparison with what their cells might contain, and the sound yielded 
upon percussion will necessarily be rather dull and insonorous. When, 
on the contrary, the respiratory process is quick, active, and energetic, 
from any cause, so as to give rise to the auscultatory phenomenon called 
puerile respiration, the percussion will be loudly sonorous, as it is in 
the later periods of childhood, owing to the thorough dilatation of all 
the air-cells, and the consequent presence in the thoracic cavity of a 
large amount of air. 

The sonorousness of the thorax is difi'erent in diff'ercnt parts in chil- 
dren, as in adults. In front, the percussion is most sonorous from just 



46 INTKODUCTORY ESSAY. 

beneath the clavicle on the right side down to one or two inches below 
the nipple, where it gradually becomes dull, owing to the position of 
the liver. On the left side the sonorousness is modified by the presence 
of the heart in the manner already mentioned. Below the prgecordial 
region we again have pulmonary resonance down to the sixth or seventh 
ribs, below which is heard the tympanitic sound of the stomach. 

Behind, the sound is very dull above the spine of the scapula, and 
considerably so over the scapula beneath its spine. Over the inter- 
scapular space it is clear and strong, and more so in the lower than in 
the upper half. Beneath the inferior angle of the scapula, likewise, it 
is clear and full, until we approach the inferior margin of the thorax, 
where it is dulled, even above the lower edge of the lungs, by the pres- 
ence beneath of the liver on one side and of the spleen on the other. 
Over the right side the dulness begins a little higher than over the left, 
in consequence of the greater bulk of the liver than of the spleen. 

The lateral regions are very resonant in their upper portions, but be- 
come dull as we approach the liver on the right side and the spleen on 
the left. On the left side the pulmonary sound is often entirely eclipsed 
by a tympanitic resonance occasioned by the presence of gas in the 
stomach. 

In practising percussion in children it is necessary to strike gently, 
because, from the great natural sonorousness of the chest in early life, 
any considerable force would bring out so much sound as to prevent the 
recognition of a degree of dulness which might readily be perceived by 
the use of more gentle blows. It is necessary always to compare the 
two sides together, as in adults, since this often leads to the detection of 
a degree of impaired resonance which might be otherwise inaj^preciable. 
Yet, and the phj^sician ought to be well aware of this, the compari- 
son of the two sides is not quite so useful in young as in mature sub- 
jects, because of the fact that the diseases in which the differential 
comparison is most important, pneumonia and pleurisy, are more fre- 
quently double than in adults. It becomes, for the same reason, very 
important to compare the upper and lower portions of the thorax 
behind, since we may assure ourselves of the existence of dulness below, 
of which we were before doubtful, by the fact that the sound is less 
sonorous in that region than above; which is, as already stated, the 
very opposite of the healthy condition. 

Examination of the Abdomen. — It is often very important to ascer- 
tain, by palpation, the form, size, and degree of tension of the abdo- 
men, the presence or absence of effusions within its cavity, and the 
condition of the organs w^hich it contains; to learn by percussion the 
degree of resonance which it affords; and, lastlj^, to find by pressure 
whether it be unnaturally tender to the touch or not. By a careful 
inquiry into these various points, and a proper comparison between 
them and the rational symptoms presented by the patient, we shall be 
able to discover the existence of tumors, of hypertrophied organs, of 
unusual developments of gas in the intestines, of dropsical effusions, of 
enlarged and hardened mesenteric glands, of gurgling, and of soreness 



EXAMINATION OF THE MOUTH AND THROAT. 47 

on pressure, caused by inflammation of some of the contents of the 
cavity. The examination should be made, if possible, whilst the child 
is still and composed. It is best, therefore, to perform it before auscul- 
tation and percussion, in children who are old enough or amiable 
enough to be willingly quiet, since the length of the examination of 
the thorax often wearies out their patience, and they refuse to submit 
to farther inspection ; whilst, in infants and in children who obstinately 
resist the examination, it matters little at what particular period it is 
attempted, since it must be done at last in the midst of cries and gen- 
eral agitation. It is, at all times, a difficult and not very useful exami- 
nation, unless the patient consents to it freely and without fear. It is 
very necessary, therefore, to resort to every means to obtain this quiet 
consent. In children over a year old, this condition is to be obtained 
only during deep sleep, daring the act of nursing, or, when the patient 
is awake, by so pleasing and attracting its attention by toj^s, by sooth- 
ing voice and manners, as to cause it to forget what is passing. The 
reasons why the examination is useless, unless made during a state of 
calm, are very obvious. In the first place, the contractions of the 
abdominal muscles give to the walls of the abdomen such a degree of 
hardness and rigidity, tliat it is impossible to learn anything in regard 
to the state of the parts within, except merelj^ what can be learned by 
percussion ; and, in the second place, no acuteness of perception will 
enable us to distina:uish between the cries of an£»;er and frio-ht, and 
those that may proceed from pain occasioned by pressure. 

M. Yalleix recommends a plan in the case of young infants, by which 
tenderness on pressure may very generally be recognized. It is as fol- 
lows : he carries the child, carefully sustained in the arms, suddenly be- 
fore a bright light, either that which pours in at a large window daring 
daylight, or that of a bright artificial light at night. The infant, whose 
greatest pleasure consists in gazing at a bright light, almost always 
ceases to scream and becomes perfectly quiet while thus attracted. 
Seizing this opportunity, the physician should pass his hand under the 
clothes, and applying it directly over the cutaneous surface, he may 
first learn, by a rapid palpation, the general characters of the abdo- 
men, and then ascertain by sudden and decided pressure whether it be 
abnormally sensitive. If the pressure gives pain, the infant will cry 
out at the moment, while, at the same time, a sudden contraction of 
the countenance will assist to show the perception of some painful sen- 
sation. Should the infant, on the contrary, continue to gaze fixedly at 
the light, without noticing the manoeuvres of the physician, it is fair to 
conclude that there is no inflammatory tenderness present. 

Examination of the Mouth and Fauces. — In all obscure attacks of 
sickness occurring in young children, and even in those who have at- 
tained to the faculty of speech, the physician ought to be most careful 
to inspect the condition of the mouth and fauces, since not a few cases 
of fever which seem at first view inexplicable, are at once made plain 
by this simple exploration. We were once called to see a child three 
years of age, who had been sick three days with fever, thought by in- 



48 INTRODUCTORY ESSAY. 

telligent and educated parents to depend on gastric derangement. A 
single look into the throat showed it to be completely clogged up with 
pseudo-membranous exudation, whilst a slight hiss in the inspiration, 
and a husky voice, declared that the same fatal product was just enter- 
ing the larynx. The time for successful action had slipped by; the 
patient died two days after in the agonies of slow croup. On another 
occasion we were called to take charge of two children in one family 
who had been ailing several daj^s with feverish symptoms, loss of appe- 
tite, languor, and some complaint of sore throat. In both we found 
the fauces covered with plastic deposit, and both died a few days after 
of membranous croup. Some years ago we attended a child between 
five and six years old, for a period of four days, with irregular fever, 
some vomiting, total anorexia, languor, indisposition to play, and rare 
complaints of pain in the chin and neck, that were not mentioned to us 
by the attendants, so that all the time we had the idea that the attack 
was one of gastric embarrassment. Greatly to our amazement and 
consternation, the mother informed us on the fifth day that she had seen 
something white in the throat, and upon examination we found both 
tonsils covered with whitish exudation. Happily the exudation was 
still confined to these glands, and we were able by appropriate treat- 
ment to prevent its further extension. 

In croup, also, in whatever form it may make its attack, the fauces 
ought to be closely watched, in order to know by the presence or ab- 
sence of false membrane, the probability or improbability of the case 
being one of the membranous kind. In scarlatina and measles, especi- 
ally in the former, the throat ought to be examined each daj^, to ascer- 
tain its precise condition, and particularly to learn whether there be 
present any disposition to membranous, ulcerative, or gangrenous 
angina. 

In young infants, also, the mouth requires a thorough examination 
from time to time in all their ailments, and especially in their digestive 
diseases, since they are liable to thrush, to aphthae, and in chronic 
and debilitating maladies, to gangrsena oris. In teething children 
the act of dentition requires that the mouth should be inspected oc- 
casionally in order to ascertain the state of that process, and to detect 
the existence of the form of stomatitis called ulcerative, which gener- 
ally occurs between the ages of one and five or six years. 

The mouth can be readily examined by pressing upon the chin with 
force sufficient to cause the child to separate the jaws. In the young 
infant this very generally produces crying, during which the mouth is 
widely opened, and the state of the cheeks, lips, gums, and tongue can 
be perfectU^ well seen. In an older child, who refuses to open the mouth, 
or to keep it open, the handle of a smooth silver spoon is the best in- 
strument to employ by which to effect our purpose. 

The throat cannot be well seen at any age, except by depressing the 
base of the tongue, which is best done by means of a spoon-handle, as 
above directed. When a child refuses obstinatel}^ to open the mouth, 
and resists with violent struggles, it should be taken on the lap of a 



MANNER OF TAKING DRINKS. 49 

strODg assistant, with the back of its trunk resting against the chest 
of the assistant, whose arms should restrain, bj being crossed over the 
body and limbs of the child, its more vehement movements. Another 
assistant must hold the head of the child steady, whilst the physician 
obliges it to open the mouth, either b}^ closing the nostrils with the 
fingers, or by slowly and gentl}^ but firml}-, insinuating the handle of 
the spoon between the teeth. After the spoon has once been passed 
over the tongue there is seldom any diflSculty in obtaining a good view 
of the fauces. 

The introduction of the finger into the mouth is of some use as a diag- 
nostic means in the case of infants. It informs us of the temperature 
of that cavity, of the state of its secretions, and consequently, of its 
dryness or humidity, and of the disposition and ability of the infant 
to suck. When an infant is in good health, it will almost always seize 
the finger, when this is placed in the mouth, and suck vigorously for 
some instants. It will do the same when it is only ailing with some 
slight malady, and in the early stage of more dangerous diseases. But, 
in severe and threatening illness, the infant either refuses to suck upon 
the finger at all, or does so only for an instant. When the mouth is 
irritated or inflamed, as in the various forms of stomatitis, the child will 
open the mouth and cry, and make no attempt whatever at suction. 
In stupor, and especially in coma, but little attention is paid to the 
finger, the infant being generally unconscious of its presence. 

By watching the child when put to the breast, we may acquire nearly 
the same information as that just referred to, except that the child 
would naturally make a greater efi'ort to seize the nipple than the fin- 
ger, and would therefore nurse, even though the act of so doing were 
painful, under circumstances in which it might refuse to grasp the fin- 
ger at all. The refusal to nurse, or the nursing but little at a time, 
may depend on other causes, however, than sore mouth. It often de- 
pends on some anginose infiammation. When this is the case, it may 
be suspected from the peculiar gulping manner in which the child 
swallows, and from the fact that swallowing often causes fits of cough- 
ing. It is caused also by dj'spnoea. An infant laboring under severe 
oppression from pneumonia, bronchitis, or any other cause, never sucks 
well and steadily, but rather by fits and starts. The nipple is seized 
often with avidity, and two or three swallows are made in quick suc- 
cession ; then follows a pause to regain the breath, and then again the 
effort of deglutition. In a few cases attended with very great dyspnoea 
that we have seen, the patients have been able to swallow only once or 
twice without pausing, and even then with very great difficulty. 

Manner of Taking Drinks. — The remarks just made as to the in- 
ferences to be drawn from the manner in which the infant sucks, will 
apply also to the mode in which both infants and older children drink. 
A young child drinks continuously, without stopping to breathe. If, 
however, it have any disorder which accelerates the respiration, it 
will, after drinking a few mouthfuls, cease, jerk its head away from 
the cup or spoon, breathe irregularly and hurriedl}^, and cough. These 

4 



50 INTRODUCTOEY ESSAY. 

sj'mptoms ought to call attention to the respiratory organs. So, if a 
child, whose breathing is not oppressed, nevertheless drinks with diffi- 
culty, slowly, at intervals, and apparently with pain, there is reason to 
suspect some impediment in the pharynx, and the fauces ought there- 
upon to be carefully examined. 

We may learn also from the manner of drinking whether the child 
is thirsty or not. When it drinks often and with avidity, and yet has 
a dry mouth, it is evident that there is very great thirst. 

YoMiTiNG AND THE DISCHARGES BY Stool. — The physician should 
never think his examination of a sick child concluded until he has in- 
quired as to the occurrence of vomiting, and as to the state of the dis- 
charges by stool. Not only, indeed, should he inquire as to these 
symptoms, but he ought by all means to inspect personally the appear- 
ance of the matters ejected. This is especially important in regard to 
the dejections, since no description of a mother or nurse, however in- 
telligent, can impart to the physician the precise and accurate idea of 
the state of those discharges which even a very rapid inspection would 
give him. 

Vomiting is of very frequent occurrence in infancy and childhood. 
Owing to the fact that the stomach is much less curved in its shape 
than in the adult, and that the oesophagus enters the organ close to 
its left extremity, vomiting and regurgitation take place with great 
readiness, and are, therefore, very common symptoms in the diseases 
of early life. 

The young practitioner must beware lest he regard all kinds of vom- 
iting in the infant as the result of disease. The nursing child is very 
apt to vomit, even when in the most perfect healthy especially if it be 
suckled at an abundant breast. This kind of vomiting, however, may 
be readily distinguished from that which depends on some morbid 
state of the health, by the circumstance of the infant's ejecting nothing 
but the milk which it has swallowed, either just as it was drawn from 
the mother, or slightly curdled, and by the fact that it suffers no incon- 
venience whatever from the act, — neither any violent effort, languor, 
paleness, nor faintness. And yet we have known a young practitioner 
to prescribe antacids and absorbents to correct this kind of vomiting, 
which is most plainly an act of nature kindly intended to rid the infant 
of any excess of food it may have imbibed. 

. In older children also, vomiting not unfrequently occurs as a conse- 
quence of overdistension of the stomach with food. When, therefore, 
after vomiting, a child seems relieved and comfortable, when any un- 
pleasant symptoms that may have existed prior to it moderate or dis- 
appear afterwards, it is fair to conclude that the act has been bene- 
ficial, and wrong to regard it as the signal of a necessity for giving 
medicine, or for regarding the child as a patient, except insomuch as 
to watch lest it be sick as an after-consequence of having had the di- 
gestive power overtasked. 

Frequently repeated vomiting, attended with retching and effort, 
and with paleness and exhaustion, or with fever, always indicates 



YOMITINa i^ND THE DISCHARGES BY STOOL. 51 

some considerable derangement of the health. It is impossible to as- 
certain the precise cause of such vomitings except by a proper consid- 
eration and comparison of all the symptoms the child may present. 
The cause may be in the stomach itself, consisting of an inflamed state 
of the organ, or it may be a simple indigestion without any inflamma- 
tory condition whatever; it may be that the cause lies in the intestine, 
being some inflammation, functional disease, or obstruction of that 
part; it may be pneumonia or pleurisy; it may be the approach of 
some of the eruptive fevers; or last, and most serious of all, the cause 
may be some commencing lesion of the brain, which, though as yet de- 
termining no proper cerebral symptoms, shall perhaps be destined, hj 
its inevitable progress, to end the patient's life. The detection of the 
particular causative condition, in an}^ of these forms of vomiting, can 
be arrived at only by a careful study of the whole constitution of the 
patient, both through the rational symptoms that may be present, and 
by a thorough inspection of the different systems of the body by means 
of the physical methods of diagnosis. 

The rule to examine with his own eyes the napkins or cloths of the 
child, ought never to be forgotten by the practitioner, when there is 
any reason to suppose that the alimentarj^ functions are at all deranged. 
The number of the stools in the twenty-four hours ought also to 
be ascertained, not loosely and carelessly, but precisely and with cer- 
tainty. Without a close attention to these two precautions, it is im- 
possible for the physician to obtain really useful and exact notions in 
regard to the nature of the disorder he is called upon to treat, or to 
judge of the degree of severity of the attack. 

We shall not attempt to consider in this place either the various un- 
natural appearances of the matters vomited, or ejected by stool, the 
amount of those substances, or the frequency with which the discharges 
take pjlace, since these various circumstances can be treated of in the 
manner they require, only when we come to study separately the dis- 
eases of which they form a part. 

We shall here conclude our remarks upon the methods to be pur- 
sued in the clinical exploration of the diseases of children. We have 
only to add the wish that those who shall honor them with their peru- 
sal, may find them of some real assistance in their subsequent studies 
of the affections of early life. They are intended, of course, chiefly for 
the student and young practitioner; but we cannot help hoping that 
they may possibly prove useful to some who have spent a longer time 
in the profession, but who have never, perchance, given any particular 
attention to the best modes of investigating the diseases of infants and 
children. 



CLASS I. 

DISEASES OF THE EESPIRATOKY ORGANS. 
CHAPTER I. 

DISEASES OF THE UPPER AIR-PASSAGES. 

SECTION I. 
PISEASES OF THE NASAL PASSAGES. 

ARTICLE I. 

CORYZA. 

Definition; Synonyms; Forms; Frequency. — Coryza is inflamma- 
tion of the mucous membrane lining the nasal passages. It is called in 
common language, cold in the head, or snuffles. 

We shall describe three forms of the disease, — the simple or mild, 
the severe, and the chronic. The severe form includes purulent and 
pseudo-membranous coryza. Simple coryza is very common at all ages; 
it occurs frequently as a distinct disorder, but still more frequently in 
connection with laryngitis, bronchitis, pneumonia, measles, scarlet 
fever, &c. The severe form of coryza is that which was called by 
Underwood coryza maligna, or morbid snuffles, and which, as he stated, 
is very different from and far more serious than what is usually called 
snuffles. Purulent and pseudo-membranous coryza rarely occur as idio- 
pathic affections, but are almost invariably connected with angina or 
other diseases. We met with one case, however, of the purulent form, 
unaccompanied by angina or other disease, in 1841, in a child seven 
weeks old. The case proved fatal. We saw another fatal case of the 
same form, connected with simple angina, in 1846, in a child five weeks 
old. Besides these two cases, we have met with four others of the 
pseudo-membranous variety, accompanied by simple angina, in children 
between two and six years of age, all of which terminated favorably. 
The two varieties of the disease occur, however, as already stated, much 
the most frequently as secondary affections in the course of other dis- 
eases, particularly measles, scarlet fever, diphtheria, &c. We shall not 
attempt in the present article to treat particularly of the cases which 
accompany the erruptive fevers. 



CORYZA — SYMPTOMS. 53 

Chronic coryza occurs almost invariably in connection with scrofula 
or hereditary s^'philis. 

CaL'Ses. — The only clearly evident canse of simple primary coi'yza, 
in most cases, is chilling of the body. Insufficient dress, — a very com- 
mon error in this country, — too low a temperature of the nursery, and 
exposure to bad weather, may often be discovered to have been the 
causes of the attack. 

The causes of the disease, in the two cases of purulent corj^za above 
referred to, were unknown. In one the nurse remarked a slight dis- 
charge of blood from the nose soon after birth, and the coryza dated 
from that time. In the other, the patient, a feeble child, was attacked 
when two weeks old without any appreciable cause. The four cases 
of the pseudo-membranous form occurred in 1845 and 1846, during an 
extensive prevalence in this city of severe scarlet fever, measles, and 
pseudo-membranous angina and laryngitis, which makes it probable 
that they depended upon the epidemic constitution of the atmosphere. 
The cases of MM. Rilliet and Barthez coincided generally with primary 
or secondary purulent or pseudo-membranous angina. From the ac- 
count given by Underwood of coryza maligna, there can be little doubt 
that it was epidemic when observed by himself and Denman. The 
latter author states that in connection with the coryza there was a 
general fulness of the throat and neck externally ; that the tonsils were 
tumefied, and of a dark-red color, with ash-colored specks, and in some 
cases, with extensive ulcerations; and that some of the children swal- 
lowed with difficulty: all of which symptoms clearly point to severe 
concomitant angina. There can therefore be little doubt but that in 
reality these were cases of nasal diphtheria. 

Anatomical Lesions. — TheSchneiderian mucous membrane is found 
reddened uniformly, or in points, rough, thickened, and sometimes soft- 
ened. \yhen pseudo-membrane is present, it exists either in fragments, 
or lines the whole extent of the nasal passages, and is mixed with 
mucus or muco-purulent fluid, in greater or less quantity. 

Symptoms. — The symptoms of simple coryza are sneezing, dryness of 
the nose at first, soon followed by discharge, which is very small in 
quantity in the beginning, and more abundant afterwards, and more or 
less disturbance of the respiration. It is only in young infants that 
this form of coryza is a disorder of any consequence in itself. In older 
children it never injures the health by its own action ; it is of importance 
merely as the sign that a cold has been taken, and ought to be regarded 
as a hint given by nature of the necessity of guarding the child more 
carefully in future. But, in infants at the breast, and very 3'oung 
children, it assumes much greater importance from the very consider- 
able obstacle it opposes to the act of respiration. At this early age, in 
fact, coryza becomes a serious and even dangerous disease. If primary, 
it causes great distress and disturbance to the child, interrupting its 
sleep, interfering w4th the act of nursing, and, in some instances, so 
impeding the function of respiration, as to bring on slight, and more 



54 CORYZA. 

rarely, dangerous asphyctic sj^mptoms. It may, undoubtedly, occasion 
in weak and debilitated children, more or less extensive collapse of the 
lungs, an accident which will explain the imperfect performance of the 
hematosic function in some cases, where the only evident disease is this 
apparently insignificant one of coryza. 

When simple coryza exists in connection with bronchitis and pneu- 
monia, it adds to the severity of those diseases. In children over three 
or four years old, and particularly in those who are vigorous, it seldom 
gives any serious trouble. But in young infants, and in weaklj^ children 
of any age, its influence upon the sj^mptoms is often very marked. The 
effort to breathe through the nasal passages, when they are partially 
or wholly occluded by the inflammatory swelling of their lining mucous 
membrane, or by abundant and viscid secretions, fatigues, and wears 
away the strength of the child, exhausts its energies, and renders it less 
able to resist the pressure of the sickness. But not only this; — as in 
primary coi-jza,, the entrance of air into the lungs is impeded, and the 
hematosic function is thereby interfered with, while at the same time, 
the existence of an obstacle to the full inspiratory^ movement, in addi- 
tion to that which exists in the lungs themselves from bronchial or 
pneumonic disease, cannot but assist in the production of that collapse 
of the pulmonary tissue, which has been found of late years to coincide 
so often with the bronchitis and pneumonia of young children, and 
especially with the former. 

The reason why corj^za causes so much difficulty in young children 
is, that they persist in the effort to breathe through the nose in spite 
of the obstruction of the nasal passages. They seem to do this instinc- 
tively, not, apparently, having the power to carry on the act of respira- 
tion through the mouth, or but for short periods only at a time. The 
constant struggle to force the air through the nose, and the necessarily 
smaller quantity that reaches the lungs, are undoubtedly the two chief 
causes of the symptoms above described as occurring in the corj'za of 
children. 

Severe Coryza begins with sneezing and stoppage of the nostrils, 
soon after which the discharge, which is the jDathognomonic symptom 
of the disease, makes its appearance. This consists of serous or mucous 
fluid in greater or less abundance, usually of a yellowish color, and 
which, at first thin and without odor, becomes afterwards thicker and 
often purulent, with a peculiar, unpleasant, but not fetid odor. In 
other cases, on the contrary, and especially when the pseudo-membra- 
nous exudation is present, the discharge is thin, and often contains 
small granular particles, which seem to be the detritus of the false 
membrane, while at other times it is ichorous or even bloody. When 
false membrane is present, it can often be seen, upon examination of 
the nostrils in a strong light, to cover the mucous membrane in the 
form of thin adherent layers of a yellowish-white color. The alse 
nasi, and sometimes the whole extremity of the nose, are red and 
swelled, and the skin, which is tense and shining, presents an.erysip- 



SYMPTOMS OF THE SEVERE FORM. 55 

clatoiis appearance. The upper lip is generally reddened, irritated, 
swelled, and sometimes excoriated, by the nasal secretions. 

The respiration is generally difficult, nasal, and snoring. When the 
nasal passages are nearly or quite filled with the secretions, the child 
being no longer able to breathe through them as in health, is compelled 
to keep the mouth open. This is exceedingly inconvenient to children 
of all ages, as it causes great dryness and stiffness of that cavity, and 
of the tongue and throat, and in very young infants, who instinctively 
respire almost exclusively through the nostrils, it is attended with such 
violent efforts as to be a chief or perhaps sole cause of the fatal termi- 
nation of some cases. In one instance that we saw, the child was seized 
with attacks of suffocative breathing, which threatened fatal asphyxia, 
whenever the passages became much impeded. Under these circum- 
stances the cleansing of the passages with a brush would afford com- 
plete relief, and, for a time, the little thing would appear to be quite 
well. Finally, however, death occurred in one of the attacks of dysp- 
noea, from sudden serous etfusion into the lungs. The difficulty of res- 
piration is greater, as we have stated, in proportion as the child is 
younger, and depends on the physiological fact already referred to, that 
at a very early age, respiration is performed almost solely through the 
nostrils, and that the child seems incapable of keeping the mouth open, 
in order to compensate for their closure. We have never observed 
cough except in cases accompanied by angina. Epistaxis occurred in 
two cases of the pseudo-membranous form, in children between three 
and five years of age. The bleeding recurred on several occasions, but 
ceased so soon as the coryza was cured. Infants refuse the breast 
when the passages are much clogged, or suckle with great difficulty 
and at long intervals. 

The character of the general symptoms depends much more upon the 
accompanying disease, in older children, than on the coryza itself, and 
it is unnecessary therefore to dwell upon them. In the two infants ob- 
served by ourselves, the principal symptoms w^ere, in the case unaccom- 
panied by angina, restlessness, weakness, emaciation, dry, harsh, and 
wrinkled skin, and violent attacks of dyspnoea; and in the other case, 
in which angina was present, there were added to these, fever and som- 
nolence. The duration, as observed by ourselves, in the two cases oc- 
curring in infants, was between two and three weeks, in the one unat- 
tended b}^ other disease, and six days in the one accompanied by angina. 
In the other four cases, which occurred in older children, the duration 
of the attack depended on the form and degree of the attendant angina. 
In one case it became chronic, and was accompanied by ulceration of 
the nasal passages. MM. Rilliet and Barthez state that they saw a 
child two 3' ears old die in three days, and another of three years in the 
same time; but as one of these cases was complicated with angina and 
croup, and the other with pseudo-membranous angina, it is clear that 
the rapid death depended rather on the accompanying disease, than 
on the coryza itself. 

The prognosis must depend on the age of the child, and the form of 



56 CORYZA. 

the attack. Simple coryza is never dangerous except in very young 
infants, and rarely in them. When, however, it occurs in a delicate 
infant, and is accompanied with either sufficient turgescence of the 
nasal mucous membrane, or with enough viscid secretion, to cause a 
nearly complete occlusion of the nasal passages, the effort to breathe 
through the nose, and the diminished quantity of air that reaches the 
lungs, will sometimes give rise to great and dangerous exhaustion, or 
to partial or fatal asphyxia. In older children this form of the disease 
is never scarcely more than an annoj^ance. 

When simple coryza occurs in connection with other diseases, whether 
thoracic inflammations, angina, or measles, it always adds, and some- 
times most seriously, to the difficulties of the patient, since the effort to 
breathe through the obstructed air-passages must assist to exhaust the 
life-forces, while at the same time a certain amount of the blood in the 
lungs, which ought to be exposed at each inhalation to the inspired air, 
is deprived of this necessary contact by the fact that less than the 
natural quantity of air is drawn through the nasal passages at each ex- 
pansion of the chest. 

The purulent and pseudo-membranous forms of coryza are always 
dangerous, whether they occur alone or as a part of other diseases. 
The two cases of idiopathic membranous coryza in infants that came 
under our observation, both proved fatal. The four cases in older chil- 
dren recovered without any difficulty. When they occur in connection 
with pseudo-membranous angina, or in the course of scarlet fever, the 
prognosis will of course depend very much on that of those diseases. 

Chronic Coryza. — Under this title we shall describe as succinctly as 
possible a form of inflammation of the Schneiderian membrane, of 
which we see a good many examples. It is characterized rather by 
swelling and thickening of the mucous membrane, as far as this can be 
seen, and by an accumulation of scabs and crusts, causing obstruction 
to the passage of the air, than bj^ a discharge. The secretions are, in 
fact, not much increased in quantity beyond their natural amount, but 
they consist of very thick mucus, or they are purulent in character. 

This form of the disease may be met with at any age, from a few 
weeks old up to puberty. Its principal cause has always seemed to be 
some faulty state of the general health, some constitutional dyscrasia. 
Like the keratitis and chronic otorrhoea of children, it makes its ap- 
pearance without any evident exciting cause whatever, or it follows 
an acute attack of catarrhal inflammation from cold, or an attack of 
measles, scarlatina, or epidemic angina. Oo one occasion, we met 
with it in three out of a family of four children. Though it is un- 
questionably very apt to occur in scrofulous children, its presence is 
not necessarily a sign that the patient is of scrofulous habit, since 
we have seen it in families in which there was no taint of that dis- 
ease, and have kuoAvn a good many of those affected by it to recover 
perfectly, and show no subsequent symptoms of the scrofulous or 
tuberculous cachexia. Its chief efficient cause appears to be a low 
state of the general health, the blood being more or less markedly 



SYMPTOMS OF CHRONIC FORM. 67 

anemical. and the nutrition of the body imperfect. In addition to the 
above conditions, it must also be borne in mind, as a fact of the utmost 
importance, tliat this form of coryza occurs frequently as a symptom of 
constitutional syphilis. 

The chief symptoms of this form of disease are of a local character. 
The breathing is at all times more or less nasal and embarrassed. 
Even in the waking state, the child will sometimes attract attention 
by the noisy and slightly oppressed character of its respiration, while 
when asleep the obstruction to the passage of air through the nasal 
passages will be so great as to give rise to symptoms which, though 
not alarming, are most annoying to those around. The obstruction to 
the passage of air through the nasal passages produces snoring or hiss- 
ing sounds, which are sometimes so noisy as seriously to disturb those 
sleeping in the same apartment. This obstruction also obliges the child 
to make much greater muscular efforts than in the healthy state, to 
supply the thorax fully with air, so that the sleep, instead of being 
quiet and easy as in health, is broken and disturbed by the unusual 
play of the muscles, and by the disordered internal sensations caused 
by the reaction upon the nervous centres of a circulating fluid less 
thoroughly decarbonized than it should be. The child tosses and rolls, 
sighs and moans, or it cries out in its sleep, or it wakes suddenly and 
frequently. 

AYhen the nasal passages are examined by a full light, they will be 
seen to be obstructed in two ways: by a thickened and injected state 
of the mucous membrane, and by the presence in them of scabs, or of 
more or less inspissated masses of mucus or muco-pus. The mucous 
membrane is also redder and more highly vascular than natural, and 
sometimes exhibits an appearance in some points as though excoriated 
or slightly eroded. There is seldom, indeed rarely, any considerable 
amount of fluid secretion, as in acute coryza; the secretions are so 
much more viscid than usual that they desiccate in the passages and 
form scabs and crusts. Kot unfrequently the surfaces become so irri- 
table as to bleed very easily. The act of blowing the nose, a rude 
touch, or a blow, will cause a considerable discharge of blood, and this 
is often the symptom for which the practitioner is particularly con- 
sulted. The voice of the child is usually characteristic; it is nasal; 
and when the obstruction is considerable this becomes a marked 
symptom. 

The general appearance of the patient almost always shows a deteri- 
orated state of the general health ; his color is too pale ; the skin is 
muddy; the expression is languid; the tissues are more flabby and 
flaccid than they ought to be; and the movements are less brisk and 
prompt than in full health. Such patients wake from their sleep loss 
refreshed than is natural ; their appetite is often capricious and poor; 
and the digestive and nutritive functions are impaired. The tongue is 
often flabby in its texture, pale, and more or less furred, the bowels are 
irregular, and the discharges often scanty, and of an unhealthy color 
and smell, or there are alternations of diarrhoea and constipation. 



58 CORYZA. 

In addition, when the case is connected with constitutional syphilis, 
some of the other evidences of this disease may usually be detected ; 
though w^e have, like West, met with cases where the coryza has been 
the only sign of the constitutional taint. 

The duration of this form of coryza is very indefinite. Under the 
most patient treatment, it often lasts for many months, and even when 
cured is very apt to return with or without apparent exciting causes, 
so that we have known it to last for several years. 

Treatment. — Simple coryza requires no treatment in children over 
two years of age, except attention to hygienic conditions. Young chil- 
dren may often be preserved from attacks of spasmodic laryngitis and 
bronchitis, by calling the attention of the mother to the strong tend- 
ency which exists during infancy and childhood to the extension of 
disease, and advising, in cases of coryza, that the child should be 
secluded in the house, or else very warmly clothed if sent out. 

In young infants, even the mildest coryza gives trouble, by obstruct- 
ing the full freedom of the respiratory act, by interfering with the 
suckling, and by the restless and broken sleep which it induces. In 
such cases, all the treatment required is to keej) the child warm, and 
to clear the nasal passages, and at the same time lubricate them by the 
occasional introduction of a camel's-hair pencil, charged with glycerin 
or sweet oil. 

When the coryza is more severe, so as to interfere a good deal with 
the respiration, it is necessary to make use of the brush frequently, to 
administer a warm foot-bath once or twice a day, and to give a few 
drops (jf syrup of ipecacuanha, with sweet spirits of nitre, every two, 
three, or four hours. In such cases, the late Dr. Charles D. Meigs was 
in the habit, for many years past, of directing a flannel cap to be put 
upon the child, and kept there for two or three days ; — a simple, and 
often most effectual mode of treatment. The cap should be removed 
after two or three days, so soon as the coryza is relieved, as otherwise 
the child is apt to become so much accustomed to it as to take fresh 
cold when it is removed. 

In infants laboring under purulent or pseudo-membranous coryza, 
the indications of treatment are to remove the secretions as they col- 
lect, and to subdue the inflammation of the mucous membrane by which 
they are produced. The first indication may be fulfilled by means of 
a brush made of long camel's-hair, by throwing water from a small 
syringe into the nasal passages, or, when the discharges are thin and 
fluid, by blowing strongly- into the nostrils, whilst the tongue is de- 
pressed by a finger introduced into the mouth, so as to allow the secre- 
tions to pass out of the posterior nares into the fauces. 

The second indication is to be fulfilled chiefly by the application of 
solutions of alum, nitrate of silver, sulphate of zinc or copper, and by 
insufiiations of different substances in powder. The best application 
is probably the solution of nitrate of silver, which may be made of the 
strength of five or ten grains to the ounce, or stronger, to be made use 
of several times a day, with a brush. We have also emploj^ed injec- 



TREATMENT. 59 

tions consisting of solutions of alum, of from three to six grains to the 
ounce. It is recommended b}^ MM. Eilliet and Barthez to make insuf- 
flations of powdered gum and alum, or of gum and calomel in equal 
parts, several times a day. There is, however, it seems to us, an ob- 
jection to this method of treatment, especially in infants, — wiiich is, 
that the powders would necessarily tend to increase the obstruction 
which already exists, to breathing through the nose. It has been j^ro- 
posed also to apply a few leeches to the mastoid process, or over the 
frontal sinuses; but it seems to us that this could scarcely ever be ad- 
visable. 

In the form of the disease accompanied with angina, an essential 
j)art of the treatment must be that of the throat affection. This will 
be considered in another place. 

The treatment of chronic coryza must be twofold : general and local. 
The most important points to be attended to in connection with the 
general treatment are the clothing, the diet, and the administration of 
tonics and alteratives. The clothing ought to be warm during the cold 
seasons of the year. Flannel, as a general rule, ought to be insisted 
upon. The arms and neck must be covered, and the legs should never 
be exposed, after the verj' mistaken fashion amongst many persons of 
the present day. The diet ought to be strengthening and nutritious. 
Fresh meats, milk, bread, and good butter, and the plainer vegetables, 
ought to be urged upon- the child. If necessary, some authority must 
be made use of by the parents to induce the patient to take a sufficient 
quantity of these plain, but nutritious articles of food. Pastry, cakes, 
candies, nuts, hot bread, sweetmeats, and all such rich, but not really 
substantial diet, should be forbidden to as great an extent as possible. 

Of the tonics to be given, the best are the preparations of iron and 
cod-liver oil. Of the former, we ^^refer commonly the sj^rup of the 
iodide of iron, from three to five drops, at four or five years of age, 
three times a day, in half a teaspoonful or a teaspoonful of sarsaparilla 
syrup. Or the Pulv. Ferri of the Pharmacopoeia may be given, either 
in the form of powder, mixed with dry sugar, in pill, or in the shape of 
the chocolate lozenge. From half a grain to a grain, three times a day, 
is the proper dose from three or four years to six or seven. The carbo- 
nate of iron may be given, if it is preferred, for any cause. Either of 
these preparations of iron, or any other that may be chosen, should be 
combined with a grain of quinine, three times a day, whenever the ap- 
petite is poor, and when the digestive process seems to be slow and 
feeble. Or the child may be made to take half a teaspoonful of the 
fluid extract of cinchona, mixed with an equal quantity of syrup of 
ginger, half an hour before the meals, while the iron is given alone 
soon after the meals. When the attack is particularly obstinate, and 
when, also, it occurs in a subject who either inherits or exhibits signs 
of the tuberculous or scrofulous diathesis, the best remedy is cod-liver 
oil, which should be given in doses of from half a teaspoonful to a tea- 
spoonful two hours after each meal. In cases of syphilitic nature, in 
addition to the above regimen and tonic remedies, we should adminis- 



60 CORYZA. 

ter the iodide of potassium, associated in obstinate cases with minute 
doses of bichloride of mercury. 

The local treatment must consist in the use of means intended to keep 
the passages clean and free from scabs and incrustations, and in the 
employment of astringent and alterative applications. When the pa- 
tient will submit, the nasal passages should be cleansed by means of a 
syringe once or twice a day, with tepid water, or milk and water, or 
with a weak solution of alum in water. The latter may be made in 
the proportion of from two to four gvains to the ounce. If the dis- 
charges are offensive, the lotion used for injection should consist of the 
solution of chlorinated soda, one, two, or three drachms in two ounces 
of water. After the use of the syringe, and more or less frequently 
through the day, according to the disposition to drj^ness of the sur- 
faces, these should be lubricated with some oleaginous application. 
One of the best is glycerin, or glj^cerin rubbed up with cold cream 
(f5j of the former to ^j of the latter); or sweet oil, or oil of sweet al- 
monds, may be used. These applications are best made by means of a 
camel's-hair brush. 

Amongst the astringent applications, the best are weak solutions 
(gr. V to X to water f^j) of the nitrate of silver, which should be used 
only once a day, or solutions of the sulphate or acetate of zinc with 
wine of opium. From two to five grains of either preparation, with a 
drachm of wine of opium, to an ounce of water, make a proper appli- 
cation. This maybe applied twice a day. One of the best means that 
we know of, however, after the use of the alum or soda injection through 
the day, is to apply the following ointment at night : R. Ungt. Hydrarg. 
E"itrat., 5ss. ; Ext. Belladonnse, gr. x ; Axungise, ^ss. — M. This has suc- 
ceeded admirably well in several cases in which we have used it. It 
should be applied, after being completely softened by a gentle heat, on 
a camel's-hair pencil, care being taken to apply it thoroughly to the 
surface of the mucous membrane itself, and not merely to the outside 
of the hardened scabs. 

The following case well illustrates the chronic severe form of coryza. 
It was in all probability of syphilitic nature, though circumstances 
rendered it impossible to determine this question. 

Case. — The subject of this case, a male, was born after an easj-, nat- 
ural labor, and appeared strong and well, with the exception of a little 
discharge of blood from the nose soon after birth and slight coryza, 
the latter of which continued until the child was five weeks old, when 
it became aggravated, and one of us was requested to visit the infant. 
It was small and puny; the skin was harsh, dry, and wrinkled, so that 
the child looked like a little old woman. It was very weak, and had 
constant secretions from the nostrils of thick, dark-colored pus. When 
the discharge collected in suflScient quantity to obstruct the passages, 
the respiration became exceedingly difficult, as the infant seemed inca- 
pable of breathing through the mouth. At such moments it seemed as 
though the child must die of asphyxia. If the nostrils were cleared 
by any means, by syringing, by the use of a brush, or by blowing into 



DISEASES OF THE LARYNX. 61 

them in the manner already described, the respiration would beconae 
easy and natural, until the discharge collected again, when the same 
scene recurred. During the paroxysms arising from the closure of the 
nasal passages, the child was entirely unable to take the breast, but 
after being relieved, had no difficulty whatever; the mouth was either 
kept shut, or if open, the tongue was observed to be pressed spasmod- 
ically against the roof of the mouth, so that it was impossible for more 
than a very small amount of air to pass over it; the respiration was 
labored, and accompanied by a loud snoring or nasal sound. There was 
no other marked symptom, except a nearly constant flatulent disten- 
sion of the epigastric region. On the day before death, the infant 
seemed better, appeared to have gained flesh, and looked more intelli- 
gent, so that the mother was greatly encouraged ; but the next day it 
was seized during one of the paroxysms of sufl'ocation, which did not 
seem to be worse than many preceding ones, with copious discharges of 
bloody and frothy serum from the mouth and nose, and died in about 
three-quarters of an hour. 

At the post-mortem examination we were not allowed to examine the 
nasal passages or throat. The stomach and bowels were healthy, but 
much distended with gas. The peritoneum was healthy, but contained 
a considerable amount of clear yellowish serum. There was serous 
efl'usion in both pleural cavities, but no traces of inflammation. The 
lungs were health}^, with the exception of some ecchymosed points, and 
general infiltration with sanguineous frothy serum. The trachea and 
bronchia were natural. The heart was larger than usual, but healthy 
in other respects. 



SECTIONII. 

DISEASES OF THE LARYNX. 
GENERAL REMARKS. 

There has been much confusion amongst writers on the diseases of 
children, until within a few years past, in regard to the diseases of the 
larynx, each one difl'ering from the other in his opinions as to the 
nature of the several disorders of that organ, and of course as to their 
classification and symptoms. From later and more rigid observation 
it has become clear, however, it appears to us, that there are but three 
diseases of the larynx which deserve to be considered as separate and 
distinct aifections; these are simple erythematous or catarrhal inflam- 
mation of the larynx, unattended with spasm of the glottis, or, as that 
symptom has been emphatically named, laryngismus; simple catarrhal 
inflammation of the larynx, attended with laryngismus, and called 
most properly spasmodic simple laryngitis, or more commonly simple, 
false, spasmodic, or catarrhal croup; and lastly, pseudo-membranous 



62 DISEASES OF THE LARYNX. 

inflammation of the larynx, properly named pseudo-membranous laryn- 
gitis, and more commonly called true or membranous croup. There is, 
moreover, another disease, of which one of the most marked symptoms 
is spasm of the glottis, or laryngismus, attended with a hoop or stridor, 
which is now known by the name of laryngismus stridulus, but which 
is called also Kopp's or thymic asthma, spasm of the glottis, and croup- 
like convulsion. This disease has often been confounded with the above- 
named affections of the larynx under the common title of croup, or 
has been supposed to constitute a distinct disease of the larynx; 
whereas now it is well known that the laryngismus whence its name 
was taken, is but one of many symptoms that mark the dependence 
of the disease upon disordered action of the reflex portion of the gen- 
eral nervous system. 

We are well aware, also, that some most competent observers de- 
scribe a purely spasmodic affection of the larynx, under the title of 
spasmodic croup, which they believe to be entirely independent of 
laryngeal inflammation, and to consist in a mere momentary contrac- 
tion of the sphincter muscle of the larynx, produced by the sympathies 
which that part holds with other parts of the body, and especially with 
the digestive apparatus. As we have never, however, in what has now 
become a very considerable experience in the diseases of children, met 
with a case of spasmodic croup unconnected with more or less evident 
catarrhal inflammation of the larynx, we are not disposed to risk in- 
creasing the confusion already attending this subject, by making addi- 
tional and more minute varieties of these affections than those above- 
named. We are quite willing to acknowledge that, in some cases of 
simple spasmodic croup, the amount of catarrhal inflammation of the 
larynx is sliglit, and that the symptoms of digestive disorder are very 
strongly marked, but in not a single instance of croup that has come 
under our notice, have we ever had reason to suppose that the croupal 
symptoms were dependent solety on simple spasm of the glottis (caused 
by some distant irritation), unattended with inflammation of the laryn- 
geal mucous membrane. In all such cases that we have met with, it 
has seemed to us that the condition of gastric, intestinal, or bilious 
disorders, might be explained in one of two ways. Either the disorder 
of the digestive function has rendered the child unusually susceptible 
to cold, by having diminished its power of resistance to the w^eather; 
or, the derangement of the bodily functions caused by the cold has 
weakened, amongst others, the digestive system, and thus brought 
about various symptoms of gastric or intestinal disturbance, or more 
commonly of indigestion. 



SIMPLE LARYNGITIS WITHOUT SPASM. 63 

ARTICLE I. 

SIMPLE LARYNGITIS WITHOUT SPASM. 

Definition: Frequency. — This disease consists of simple erythema- 
tons or catarrhal inflammation of the mucous membrane of the larynx, 
unattended with spasmodic closure of the organ. It is sometimes 
attended with ulceration, but is unaccompanied by exudation of false 
membrane. The frequency of the disease, during infancy and child- 
hood, is very considerable ; so much so, that not a winter passes with- 
out our meeting with a good many well-marked cases. 

Predisposing Causes. — The disease occurs at all periods of child- 
hood, but seems to be more frequent under than over five years of age. 
Of sixty-two well-marked primary cases that we have met with in 
which the age was noted, fifty occurred in children under, and only 
twelve in those over that ao'e. Of the former class, twelve were under 
one year, seventeen between one and two, nine between two and three, 
five between three and four, and five between four and five. Of sixty- 
four cases in which the sex was noted, thirty-six occurred in boys, and 
twenty-eight in girls. As to the influence of the seasons, it may be 
stated that it is by far the most common in the fall, winter, and spring 
months. 

The only exciting causes of the disease which appear to have been 
ascertained with any certainty, are the action of cold, the positive influ- 
ence of which cannot be questioned; the inspiration of irritating sub- 
stances, such as gases, smoke, powders floating in the air, &c. ; and vio- 
lent efforts of crying. MM. Rilliet and Barthez state that they have 
twice known erythematous and ulcerative laryngitis to follow long- 
continued and violent crying; and M. Billard also cites this as a cause. 
We are acquainted with one case in which a slight attack of the dis- 
ease appeared to have been brought on solely by loud and obstinate 
screaming. 

The disease is very apt to occur in the course of other maladies, and 
particularly of measles, small-pox, scarlet fever, bronchitis, and j^neu- 
monia. 

Anatomical Lesions. — The anatomical alterations may consist of 
simple inflammation of the mucous membrane, with its various effects, 
or of the same changes in connection with ulceration. The latter class 
of lesions is almost always confined to secondary cases. In the former 
class, the mucous membrane varies in color between a deep rose and 
violet red, which may be either uniform or only in patches. In severer 
cases, the tissue is at the same time softened or roughened, and some- 
times thickened. When redness, softening, and thickening are present, 
the disease is generally confined to certain parts, and commonly to the 
epiglottis, and internal portions of the vocal cords; but when redness 
alone exists, it usually affects the whole of the larynx, and sometimes 



64 SIMPLE LARYNGITIS WITHOUT SPASM. 

extends to the trachea. In cases attcDcled with ulcerations, these alter- 
ations exist in connection with those already described. The ulcera- 
tions are generally small, few in number, very superficial, linear in 
shape, and are almost always found upon the vocal cords. They are 
so slight often as to escape observation, unless a very careful examina- 
tion be made; and this, perhaps, explains the circumstance of so few 
persons having met with them in the simple acute disease. 

Symptoms; Course; Duration. — The attack generally begins with 
an alteration of the voice or cry. In infants the change in the cry alone 
exists, so that to detect the disease,it is necessary to hear the child 
cr}'. In older children the same alteration of the cry is present, but 
there is in addition a change of the voice, consisting of various degrees 
of hoarseness. These symptoms may be so slight as to be observed in 
the cry onl}^ when it is strong and forcible, and in the voice so as to 
strike only the ear of one accustomed to be with the child; or they 
may be so marked as to be heard in the faintest cVy that is uttered, 
and to be evident in the voice in a moment to the most careless 
observer; or there maybe complete aphonia. They are often inter- 
mittent in this form, and are generally most marked in the after part 
of the day and during the night. Simultaneously with this symptom, 
or very soon after, cough occurs. This is generally hoarse and rough, 
and early in the attack, dry ; at a later period it usually becomes loose, 
and as this change occurs loses its character of hoarseness. The fre- 
quency of the cough is variable, but usually moderate; as a general 
rule it is most frequent in the evening, and early in the morning, par- 
ticularly in infants and young children. The disease is almost always 
preceded and attended with some corj^za, which, in the early stage, is 
marked by sneezing and slight incrustations about the nostrils, and at 
a later period, by mucous and sero-mucous discharges. The respiration 
remains natural, except that it is sometimes nasal, and sometimes a 
little accelerated. There is rarely any fever, or it is slight, and occurs 
only at night. There is no pain in the larynx. In some cases, the 
hoarseness of the cry, voice, or cough scarcelj^ exists, or is but slightly 
marked, and the only symptom is a dry, hard, teasing, and paroxysmal 
cough, which, from its sound, evidently- proceeds from the larynx, and 
resembles very much that produced by the tickling of a foreign body 
in the throat. 

The symptoms of this disease, instead of being of the mild character 
just described, may be much more severe. The cough is more frequent, 
hoarse, troublesome, and painful, from the scraping and tearing sensa- 
tions it occasions in the larynx. The voice is more affected, becoming 
from husk}- more and more hoarse, though it is very unusual for it to 
become weak and whispering, as in membranous and severe spasmodic 
croup. The respiration is decidedly accelerated, giving rise to slight 
dyspnoea, and there is more or less fever, which is most marked usually 
in the after part of the day and in the night. The pulse is more fre- 
quent than in health, rising to 120 or 130 in the minute; the skin is 
hot and dry; the child is thirsty, restless, and uncomfortable. After a 



SIMPLE LARYNGITIS WITHOUT SPASM. 65 

few days usually, the cough becomes loose and easy, and ceases to be 
painful ; the voice loses its hoarse tone gradually, the fever disappears, 
the appetite and gayety return, and the child regains its usual health. 

When the laryngeal inflammation becomes violent in this disorder, 
so as to be attended with considerable swelling of the mucous mem- 
brane, the case always, according to our experience, assumes the shape 
of grave spasmodic laryngitis. To our article upon this latter affec- 
tion, spasmodic croup, we must refer the reader for further informa- 
tion on this point. 

In nearl}^ all the cases of this form of laryngitis that have come 
under our observation, we have found, upon examining the fauces, 
more or less decided inflammation of the tonsils, soft palate, and phar- 
ynx. In cases following a rather chronic course, from two to four or 
six weeks, which are rarely accompanied by fever or hoarseness, ex- 
cept at the invasion, and sometimes in the evening, the pharyngeal 
mucous membrane presented a roughened, thickened appearance, and 
the tonsils and uvula were more or less enlarged and tumefied. 

Thei-e is a form of obstinate, troublesome cough, to which children 
are subject, and of which we have met with a good many examples, 
that must be noticed here. It depends evidently upon chronic inflam- 
mation, with thickening of the mucous membrane lining the upper 
portion of the larj^nx. Of this we feel assured, not from any post- 
mortem examination, since we have never known a child to die of, or 
while laboring under the affection, but from the tone and character of 
the cough, from its occasional association with hoarseness of the voice, 
from its being almost invariably coincident with thickening and granu- 
lation of the pharyngeal mucous membrane, and from the fact that 
the most careful phj'sical examination of the chest fails to reveal any 
disease whatever of the lungs. The cough is harsh, rough, and, so to 
speak, tearing in its character. It often sounds, especially towards 
evening and in the earl}' part of the night, croupal in its tone. It is 
usually very frequent, not so much, however, during the dstj, as in the 
evening and night. It is very generally increased by the horizontal 
position, so that when the child is put to bed, he will begin to cough 
violently and almost incessantly, and will continue to do so for one, 
two, and even three or four hours. The cough is so constant and so 
severe as to cause the greatest disturbance not only to the patient, 
who will toss and turn in bed in the most restless manner, but to the 
mother or attendants, who are excessively annoyed, and sometimes 
alarmed, by its constancy and obstinacy. Children who become sub- 
ject to this species of cough, often have repeated attacks during the 
cold seasons of the year, the slightest exposure sometimes bringing 
them on. Each attack may last from a few days to several weeks. 
In one case we knew it to last, without once entirely ceasing, three 
months, and in another it lasted, with imperfect suspensions of a few 
days, during the same length of time. Both these cases occurred in 
hearty boys, one in- the second, and the other in the third year of life, 
and yet both were vigorous and health}^ children, as time has shown. 

5 



66 SIMPLE LARYNGITIS WITHOUT SPASM. 

In many other instances, we have known it last two, three, and four 
weeks, proving all that time most troublesome and rebellious to treat- 
ment. During the day, the child generally seems perfectly well, or at 
most merely a little pale and languid, and he coughs but moderately, 
but as soon as night comes on, and especially when he is put to bed, 
the cough begins, and goes on for hours, as stated above, unless some 
remedy, and particularly some opiate, be given to check it. It is most 
annoying to the practitioner, for he finds that his usual remedies act 
merely as palliatives. They check and modify, perhaps overcome it 
for a time, but the next change in the weather, and especially the least 
exposure to cold and damp, start it afresh, and he has to resort again to 
the same round of treatment to subdue it. To the members of the 
family also it gives great anxiety. At first, they fear it must run into 
croup, which, however, it very seldom does, and then, finding how 
difficult it is of cure, and how often it recurs, they can scarcely be per- 
suaded that it does not depend on some serious disease of the lungs. 

The principal cause of this form of chronic larjmgeal irritation is, so 
far as we have been able to ascertain, an unusual susceptibility of the 
laryngeal mucous membrane, sometimes the result of a congenital 
idiosyncrasy, and at other times the result of influences coming into 
action after birth, and especially of improper dress. We have gener- 
ally met with it in children dressed upon the hardening system so 
much in vogue with many of our most highly educated citizens. The 
low frock, leaving the neck and upper half of the chest exposed to the 
air, the bare arms and bare legs, persevered in through our cold au- 
tumns, winters, and springs, have certainly, in most of our cases, been 
the cause of this troublesome and chronic cou<j;h. 

Our experience since the publication of the last edition fully con- 
firms the truth of these remarks upon the style of clothing just re- 
ferred to. We certainly do not see so many cases of obstinate larjn- 
geal cough as we formerly did, for the simple reason that but few of 
the families we take care of, adhere to the old-fashioned system of 
leaving their children half naked. 

The duration of the disease varies according to its form and the cir- 
cumstances under which it occurs. When primary, it lasts usually from 
a few^ days to one or two weeks, but when it becomes chronic, as we 
have known to happen in a good many instances, it has lasted from 
two to four or six weeks, and even two or three months. The dura- 
tion of secondarj^ cases depends, of course, upon that of the disease 
during which they occur. 

Diagnosis. — The diagnosis of simple laryngitis is very easy. The 
hoarseness of the cry, voice, and cough, the redness of the mucous 
membrane of the pharynx, and the absence of general symptoms, will 
distinguish it from any other aff'ection. In somewhat severer cases 
of this form, in which the cough is more frequent and harassing, the 
general symptoms more strongly marked, and the respiration some- 
what hurried and oppressed, the attack may at first view present the 
appearances of bronchitis or pneumonia. The absence of the phys- 



TREATMENT. 67 

ical signs of these affections will show at once, by negative evidence, 
the true nature of the case. 

In some cases in which there is little or no hoarseness of the voice 
or cough, the symptoms strongly resemble the early stage of hooping- 
cough. We have met with five instances in which it was difficult not 
to believe, for two and three weeks, that the attack was really one of 
that disease. In one of these the resemblance was so close, that for 
several days there was a distinct hoop during the fit of coughing, with 
vomiting at the close of the paroxysm. The grounds for deciding that 
the case alluded to was not one of pertussis, were, that the attacks 
came on like laryngitis, after measles, and that the paroxysms occurred 
only at nigiit. * In the other cases a correct diagnosis was arrived at 
only by attention to the state of the fauces, w^hich are almost always 
more or less inflamed and thickened in laryngitis, whilst they are not 
so in pertussis, and by watching the progress of the sickness. 

Prognosis. — The prognosis is always favorable in the mild form of 
the disease. We have never met with a fatal case. 

Treatment. — The treatment of the milder cases of this form of lar^m- 
gitis ought to be very simple. Children under four or five years old 
ought to be confined for the first few days to the house, unless the 
weather be diy and not intensely cold. In mild weather they may be 
sent out for a short time in the middle of the day. When the patient 
is five or over, he may continue to go out through the day, unless the 
weather be verj^ bad. Much must depend upon the peculiarities of the 
child's own constitution. These can only be learned by observation 
on the part of the mother. Some children bear going out with such 
attacks perfectly well ; others, if sent out with this simple laryngitis, 
are almost certain to have spasmodic croup or bronchitis more or less 
severely. When there is any febrile movement in the case, no matter 
how slight, the child ought to be kept quiet, and confined to the house. 
Attention to this point, therefore, careful management of the clothing, 
slight reduction of the diet if there be any fever, a warm foot-bath at 
night of simple water, or of water containing a little mustard, the appli- 
cation of some slightly stimulating liniment to the front of the neck and 
throat twice a day, and the occasional internal administration of some 
gentle expectorant and anodyne dose, constitute all that is necessary 
in the great majority of cases of this kind. The best internal reme- 
dies are a few drops of syrup of ipecacuanha, with paregoric, lauda- 
num, or solution of morphia given every evening as the child is put to 
bed, or occasional!}^ through the da}^ also, if the cough is troublesome. 
A combination of syrup of seneka with that of ipecacuanha, will often 
be found very serviceable. 

The treatment of the chronic laryngeal cough, unattended by fever 
or any severe constitutional symptoms, described above, requires some 
special remarks. In the first place, we have to state that we have 
seldom succeeded in curing it until we had obtained from the parents 
their consent (often obtained with great difficulty) to a proper dress 
for the child. Expectorants, nauseants, opiates, antispasmodics, coun- 



68 SIMPLE LARYNGITIS WITHOUT SPASM. 

ter-irritants, and local applications, have nearly always failed to pro- 
cure more than temporary alleviation, until the child has been dressed 
warmly. We have cured, on several occasions, this kind of cough, 
after many ineffectual trials with the above remedies, only by insisting 
upon a mode of dress which covers the neck, arms, and lower extremi- 
ties. A merino or soft flannel shirt, with long sleeves and high neck, 
long merino stockings, and thick muslin or canton-flannel drawers, have 
done more in such cases to eff'ect a cure than all other means. This 
style of dress has removed the cause, the constant chilling of the body, 
and then the usual therapeutic measures will, no doubt, assist in over- 
coming the local changes which constitute the disease. 

The best therapeutic measures to be adopted in such cases are the 
application, once a day, of a solution of nitrate of silver, of from five 
to twenty grains to the ounce, low down into the pharynx and chink 
of the glottis, by means of a small sponge-mop on a bent whalebone. 
After several applications have been made daily, they should be made 
only once in two or three days. The strength of the solution is to be 
determined by the condition of the pharyngeal mucous niembrane, as 
we may assume this to mark, in some measure, the state of the con- 
tiguous tissue of the glottis. When the mucous membrane of the fauces 
is covered with large, protuberant follicles, when the tissue between 
the follicles is thickened, relaxed, spongy-looking, and when the color 
of the membrane is dark red, the stronger solutions are the best; when, 
on the contrary, the mucous membrane is not roughened or thickened 
materially, when the follicles are small, when the color of the tissues 
is bright red, it is best to use only the five-grain, or even a weaker 
solution. The most useful internal treatment in our hands has been 
the exhibition, three times a da}^ of one of the following mixtures, 
preferring that with antimony for a vigorous child, and that without 
antimony for one less robust. 



R- 


—Potass. Carbonat., 


. . . BJ. 




Yin. Antimon., . 


.. fgss. velj. 




Tinct. Opii, .... 
Syrup. Simp., 
Aq. Cinnamom., . 
Ft. Mistura. 


. gtt. xxiv, vel xlviij 

• . . f^j. 

. . . fgij—M. 


R- 


—Potass. Carbonat., 


. . . BJ- 




Tinct. Opii, .... 
Syrup. Senegas, . 
Syrup. Tolutani, . 
Aq. Fluvial, 
Ft. Mistura. 


. gtt. xxiv, vel xlviij 

• . . fSiJ. 

• . . f^vj. 

. . . f^ij.-M. 



One of the most troublesome cases of cough we ever met with, oc- 
curred a few years since in a fine, intelligent, but not robust boy, four 
years old. He was seized with a hard, obstinate cough, which, in a 
few days, became really terrible from its almost incessant repetition 
for many hours at a time. The cough was dry, tickling, choking, re- 



SPASMODIC SIMPLE LARYNGITIS. 69 

peated with nearly every breath, and so incessant as to drive the 
parents — and we may add the doctor — almost frantic. The little fel- 
low at last found out, instinctively, that, by placing himself on the 
front of the bodj' on two pillows, with the chin hanging over the edge 
of the upper one, he coughed less frequently, and with less violence, 
than in any other position. Discovering that the uvula was very much 
leno'thened from relaxation and eloncjation of its mucous membrane, 
we touched the lower sharp extremity with the lunar caustic stick 
twice a day. At the same time the following mixture, which we had 
often used to control general nervous irrjtability in children, was pre- 
scribed; and this, with the lunar caustic application, finally controlled 
the cough. It was as follows: 

R. — Yin. Antimonii, ........ gtt. xlviij. 

Ext. Yalerianoe FL, 

Tr. Opii Camph., aa f^ij. 

Syrup, Simp , . f^^s. 

Aquse, f^j. — M. 

S. A teaspoonful every hour or two when the fits of coughing set in. 

After a few daj'S, when the irritability of the fauces was somewhat 
subdued, the elongated portion of the mucous membrane of the uvula 
was cut off close to the muscle, and there was no renewal of the cough 
afterwards. 

When the cough is very harassing at night, from two to four drops 
of laudanum, wdth from ten to twenty drops of syrup of ipecacuanha, or 
two grains of Dover's powder, given once or twice in the evening, have 
answ^ered better than any other means. When the patient presents an 
anemical appearance, or other symptoms marking a general deteriora- 
tion of the health, iron, and especiall}^ the syrup of the iodide of iron, 
given three times a day, has assisted in removing the cough, and es- 
pecially in lessening the extreme susceptibility of the system to changes 
of the weather. The diet ought to be light, but strengthening. Good 
fresh meat, with simple nutritious vegetables for dinner, and bread and 
milk morning and evening, constitute the most proper diet. In bad 
weather, during the cold seasons of the year, the child should be con- 
fined to the house. 



AETICLE II. 

SPASMODIC SIMPLE LARYNGITIS, OR SPASMODIC OR FALSE CROUP. 

Definition; Synonyms; Frequency; Forms. — Spasmodic laryngitis 
is a disease of the larynx almost peculiar to children, consisting of 
simple catarrhal inflammation, without pseudo-membranous exudation, 
of the mucous membrane of that organ, attended with spasmodic con- 



70 SPASMODIC SIMPLE LARYNGITIS. 

traction of the glottis, or laryngismus, occasioning violent attacks of 
threatened suffocation. 

It is the disease commonly called in this country croup, or, by those 
who make the distinction between it and pseudo-membranous laryngitis 
or true croup, spasmodic croup. It is known also by the names of false 
or pseudo-croup. We prefer the term spasmodic laryngitis, because 
it is expressive of the essential characters of the disease. It is the 
stridulous laryngitis of MM. Guersent and Yalleix; the stridulous an- 
gina of M. Bretonneau ; the acute asthma of infancy of Millar; and the 
spasmodic croup of Wichmann, Michaelis, and Double. It is not the 
laryngismus stridulus described by the English authors, Kerr, Ley, 
and Marsh, which is the same as the thymic or Kopp's asthma of the 
Germans, and spasm of the glottis of the French. It is called by Dr. 
Wood, in his work on the practice of medicine, catarrhal croup. 

Spasmodic larj^ngitis is one of the most frequent of the diseases which 
occur during childhood in this country. It is so common in this city, 
that almost all mothers who have had any experience in sickness, keep 
some remedy for it in their houses, which they are in the habit of re- 
sorting to upon their own judgment. 

During the last 20 years we have had under our charge 109 cases of 
the disease, of which we have kept an accurate record, and at least 100 
other cases, of which we ];iave no written account. Of the 109 cases, 
86 were of the mild, and 23 of the severe form. 

We shall describe two forms or degrees of this disease, the mild and 
the severe. Without this distinction it would be impossible to give an 
accurate account of the disorder, since the two forms differ so much in 
aspect as to render them almost as much unlike as though the}' were 
two distinct affecftions. Moreover, the mild form differs so widelj' from 
membranous or true croup in its course and symptomatology, that the 
distinction between the two is readily made out, whilst the severe form, 
on the contrary, resembles true croup so much as to demand often very 
nice powers of observation to distinguish them, and yet the distinction 
is one of vast consequence to the patient, since the prognosis and treat- 
ment are widely different in the two diseases. 

Predisposing Causes. — The disease is much more common -at some 
ages than others It occurs most frequently during the period of the 
first dentition, being more common in the second year of life, which is 
the time of greatest activity of the first dentition, than at any other age, 
though it is often met with also in the third and fourth years. In the 
fifth year it still occurs occasionally, in the sixth and seventh it becomes 
rare, and after the seventh we have seen it but a few times. Of 106 
cases of the disease that we have attended, in which the age was noted, 
8 occurred in the first year of life, 33 in the second, 22 in the third, 26 
in the fourth, 12 in the fifth, 2 in the sixth, 2 in the seventh, and 1 in 
the eighth. 

It is said to be more frequent in boys than girls, and this seems borne 
out by our own experience, since of 106 cases, 62 occurred in boys, and 
44 in girls. 



ANATOMICAL LESIONS. 71 

Spa?;modic croup occurs nsnally as a sporadic disease, but is said by 
some authors to prevail at times as an epidemic. We have never had 
anv reason to suppose that it ^vas strictly an epidemic like membran- 
ous croup, which appears to a considerable extent in some years, and in 
others is scarcely seen. We believe rather that the unusual prevalence 
of spasmodic larvnijitis at certain periods, in comparison with others, 
depends on the fact that certain states of the weather or season predis- 
pose or excite to it in a greater de_i!:ree than usual, and thus occasion a 
larije number of children to be attacked with it. 

It is generally believed to be hereditary in certain families, and of 
this we ourselves have no doubt. We are acquainted wrth one family 
in this city, in which the children for three generations were extremely 
liable to it ; with another, in which the grandmother and grandchildren 
were frequently attacked ; and with a third, in which the father and 
children showed the same predisposition in the most marked manner. 
The idea is, moreover, entertained by many people in this community. 

The natural constitution of the child does not seem to have much 
influence upon the liability to the disease; it occurs indifferently in the 
weak and strong. We have no doubt, however, that there are certain 
transient conditions of the health which do affect the liability to it, 
since it has long been remarked that disturbances of the digestive func- 
tions fj-equently invite it, and since w^e have often ourselves found it 
most apt to attack those who are liable to it, when they happen to be 
laboring under bilious disorders or indigestions. It is most common 
during cold weather. 

Exciting Causes; Cold. — By far the most frequent exciting cause 
is the action of cold ; either the passage from a warm into a cold atmos- 
phere, or prolonged exposure to cold and damp. It has been known on 
several occasions to follow long-continued crying, doubtless from inflam- 
matory action set up in the larynx, as a consequence of the excessive 
determination of blood to that part during the act of crying. We were 
assured, some time since, by a very intelligent woman, that her little 
daughter had, at the age of two years, a well-marked attack of croup, 
after a severe and long-continued fit of cr3nng from some contrariety. 

Anatomical Lesions. — Mild cases of spasmodic laryngitis are so 
rarely fatal, as to leave us in some doubt as to the character of the 
anatomical lesions, or whether there are indeed any perceptible altera- 
tions of the tissues. We have never ourselves met with a fatal case of 
this form, and are therefore unable to give any personal account of the 
condition of the larynx, though we have never doubted, from the nature 
of the symptoms, the hoarseness, the dry cough, which afterwards 
becomes loose, and the whole aspect of the disease, that the anatomi- 
cal condition of the affected organ must be one of slight inflammatory 
hypersemia. In some cases, however, that have been examined, a little 
mucus in the larynx, and slight redness have been found, while in 
others no change has been detected. Dr. Wood (^Treat. on the Prac. of 
Med., vol. i, p. 779) accounts for this absence of morbid appearances in 
the following plausible manner: "In some rare instances, no signs of 



72 SPASMODIC SIMPLE LARYNGITIS. 

disease are discovered in the mucous membrane, and the patient has 
probably died of spasm, consequent upon high vascular irritation or 
congestion, the marks of which disappear with life." 

Cases of severe spasmodic croup have not unfrequently proved fatal, 
and the anatomical alterations of this form of the disease have there- 
fore been well ascertained. These alterations consist of either simple 
catarrhal inflammation of the lar3'ngeal mucous membrane, or of inflam- 
mation attended with ulceration. When the inflammation is simple, 
the membrane is changed in color, either uniformly or in spots, to a 
deep rose or dark-red tint. This may be the only alteration, or the 
tissues may be^found also softened, or roughened and thickened. When 
the redness, thickening, and softening, are all present, these appear- 
ances are usually confined to certain parts, and particularly to the epi- 
glottis and vocal cords, but when redness alone is present, it generally 
affects the whole of the larynx, and may extend to the trachea. To 
the alterations just described are sometimes added, as was stated above, 
ulcerations. These are commonly small, few in number, of a linear 
shape, and are usually seated upon the vocal cords. They are so slight 
as to escape observation, unless carefully looked for. 

Symptoms; Duration. — The invasion of the mild form of spasmodic 
croup is generally very sudden, for though it is often, probablj' in a 
large majority of cases, preceded for a few hours or a day or two by 
slight coryza, hoarseness, and cough, these symptoms are seldom 
noticed at the time, and the child is not supposed to be sick until 
seized with the paroxysm of suff'ocation, which is pathognomonic of the 
disease. This occurs in much the laro;er number of cases during; the 
night, and very generally wakes the child from sleep. Of sixty-four 
cases observed by ourselves, in which the time of the attack was noted, 
it occurred in the night in sixty-two, whilst in two it came on in the 
afternoon. The period of the night at which it takes place is very 
irregular, but it is much more apt to be before than after midnight, as 
is shown by the fact that of forty-two cases in which this circumstance 
was ascertained, the attack was before midnight in thirty, and after in 
twelve. This agrees very closely with the statement of MM. Eilliet 
and Barthez, that it has been observed most frequently at eleven in 
the evening. The duration of the paroxysms varies considerably, and 
depends a good deal upon the treatment employed. They may last 
from a few minutes to several hours, but are seldom shorter than from 
half an hour to an hour. The number of the attacks also varies. In 
some cases there is but one, though very generally there are several. 
When the attack occurs early in the night, it is very apt to recur again 
towards morning, and, unless means of prevention are used, on the 
following night also, and even, though this happens much more rarely, 
on the third night. As a general rule, the first attack is the most 
severe. 

When the paroxysm comes on, the child is wakened from sleep by 
the sudden occurrence of symptoms apparently of the most alarming 
and dangerous character. These consist of loud, sonorous, and barking 



SYMPTOMS. 73 

cough; of prolonged and labored inspiration, accompanied by a shrill 
and piercing sound, to which the term stridulous is applied ; of rapid 
and irregular respiration, amounting often to violent dyspnoea, or seem- 
ingly impending suffocation : the child, alarmed and terrified at its con- 
dition, and at the fright of those around, its countenance expressive of 
the utmost anxiety, cries violently between the attacks of coughing, 
and begs to be taken on the lap, or sits up or tosses itself upon the 
bed. struggling apparently with the disease, which seems for the 
moment to threaten its very existence. The voice and cry are 
hoarse, and sometimes almost extinguished during the height of the 
paroxysms, but become distinctly audible, and often nearh^ natural, in 
the intervals between them ; differing in this respect from pseudo-mem- 
branous croup, in which they remain permanently hoarse or whisper- 
ing. We have never heard, in this disease, the whispering voice and 
the short smothered cough of true croup. The face, head, and neck are 
at first deeply flushed, and as the paroxysm becomes more violent, 
assume a dark livid tint, which afterwards passes into a deadly pale- 
ness, if the attack be long continued. These changes in the coloration 
depend upon the arrest of the respiratory function and a consequent 
partial asphyxia. The pulse is frequent during the paroxysm, and the 
skin sometimes heated. After a longer or shorter period, generally 
from half an hour to an hour, the respiration becomes more tranquil; 
the stridulous sound disappears entirely, unless the child be disturbed 
and made to cry, when it again becomes distinct; the cough is less fre- 
quent and less boisterous, and the child generally falls asleep. The 
attack is very apt to recur towards morning, as has been stated, and 
if not then, the following night. The patient often seems perfectly 
well the day after the first paroxysm, with the exception, perhaps, of 
slight cough. This is no reason, however, for supposing that the dis- 
ease will not return in the course of the second night, which is almost 
sure to happen, unless measures be taken to prevent it. The cough 
generally continues for a day or two, but soon loses the peculiar char- 
acter expressed b}" the term croupal ; it becomes less frequent and more 
loose, and the child is commonly well again in two or three days. 
Sometimes, however, the cough lasts for several days, becoming gradu- 
ally less frequent, until at last it ceases entirely. 

Thereis very little fever in mild cases, for though the pulse is accele- 
rated and the skin warm during the paroxysm, these symptoms disap- 
pear very soon after that is over. In more severe cases, on the con- 
trary, there may be considerable fever, the pulse becoming frequent 
and full, and the skin hot. The febrile movement is most apt to occur 
after the first paroxysm, as a consequence, apparently, of the slight 
catarrh which remains after the attack. 

In the few fatal cases on record, the paroxysms have generally be- 
come more frequent and more violent by degrees, and death has oc- 
curred from suffocation. In other instances, death has been the result 
of prostration, which itself has probably depended on imperfect 
hematosis. 



74 SPASMODIC SIMPLE LARYNGITIS. 

Eecnrrences of the disease are ver}^ common, children sometimes 
having several attacks in a single winter. This is not the case in true 
croup. We have known but two children to have a second attack of 
that disease. 

The severe form of spasmodic laryngitis may begin as such or result 
from an aggravation of the mild form; or the case may commence as 
one of simple larj^ngitis without spasm of the glottis, and as the in- 
tensity and extent of the laryngeal inflammation increase, it may as- 
sume all the features of the form under consideration. AVhatever be 
the mode of onset of the case, this form of the disease sets in with 
hoarse, frequent cough, difficult respiration, restlessness, and more or 
less violent fever, sj'inptoms which almost always become severe for 
the first time at night, and usually between early evening and mid- 
night; though, in some few cases, they make their first appearance 
during daylight, and this is very much more apt to happen in tliis 
than in the mild form of spasmodic croup. During the night the 
symptoms increase in severity; the respiration is frequent and diffi- 
cult, and. after a time, attended with the stridulous sound in inspira- 
tion and expiration caused by narrowing of the glottis: the cough is 
hoarse, dry, and croupal, and unattended with expectoration ; the voice 
becomes hoarse, and fever sets in, the pulse becoming full and fre- 
quent, the skin hot and dry, and the face flushed. These symptoms 
persist, with greater or less severity, throughout the night, while from 
time to time, they increase to such an extent as to seem to threaten 
suffocation, resembling then exactlj^ the paroxysms described as occur- 
ring in the mild form of the disease. They usually subside, however, 
very decidedly towards morning, the breathing becoming easier, the 
stridulous sound less loud, or ceasing altogether, the fever diminish- 
ing, and the patient becoming in all respects much more comfortable. 
This amelioration of the child's condition often continues until the 
after-part of the day or till evening, when the same train of symptoms 
reappears. In other cases the disease scarcely subsides at all for two, 
three, or four days, but continues throughout the day and night to 
exhibit the same symptoms as have been described above. In cases of 
this kind, which are not rare, the disease assumes many of the alarm- 
ing and dangerous characters of pseudo-membranous laryngitis or true 
croup, and it becomes very difficult often to distinguish between the 
two. If no favorable change take place, the dyspnoea becomes so vio- 
lent as to threaten suffocation ; the cough is rare and short ; the voice 
is reduced to a mere whisper; the pulse becomes small, extremely ra])id 
and thready ; the countenance, at first livid and congested, assumes a 
pale, cadaveric appearance; the features are contracted; the child be- 
comes comatose or delirious, and death occurs from slow asphyxia, or 
sometimes in an attack of general convulsions. 

In favorable cases, on the contrary, the dyspnoea, and especially the 
stridulous sound, diminish ; the cough becomes loose, less hoarse, and 
loses its croupal character; expectoration of mucous sputa takes place 
in older children, whilst in younger, the loose gurgling sound produced 



NATURE OF THE DISEASE. 75 

by the discharge of the sputa into the fauces, is heard at the tei-mina- 
tion of each cough ; the voice becomes clearer and stronger; the fever 
diminishes; the child regains its spirits and disposition to be amused; 
and soon all dangerous symptoms have disappeared, and the recovery 
is established. 

In nearly all the cases that have come under our observation, we 
have found, upon examining the f\xuces, more or less decided inflam- 
mation of the tonsils, soft palate, and pharynx. 

The duration of the severe form of spasmodic croup depends on the 
violence of the attack, and on the mode of treatment. When the treat- 
ment is begun with from an early period, the disease is much sooner 
overcome than when allowed to run on forsome time without remedies. 
In cases of moderate severity, the violence of the symptoms usually 
subsides after thirty-six or forty-eight hours. In more violent cases, 
on the contrary, the sj'mptoms seldom subside definitively before the 
third, fourth, and not unfrequently the fifth day. In no case that has 
come under our observation, has the disease continued to present 
dangerous s\^mptoms after the fifth day, unless, as not unfrequently 
happens, the inflammation spreads to the bronchia or tissue of the 
lungs, producing bronchitis or pneumonia. But even after the signs 
of severe laryngeal inflammation have disappeared, there almost always 
remains for several days longer, some cough and huskiness of the voice, 
marking that the mucous membrane of the larynx has not yet regained 
completely its healthy condition. The disease is said to have proved 
fatal in twenty-four hours. 

JSTature of the Disease. — Authors hold yqyj different opinions as 
to the nature of spasmodic laryngitis. By Underwood, Dewees, and 
Eberle, it is confounded with membranous laryngitis, they making no 
distinction between false or catarrhal, and true or membranous croup. 
Dr. Cheyne {Cyclop, Pract. Med., Art. Croup) treats of the two affec- 
tions as one and the same disease, differing only in their degree of vio- 
lence. Dr. Copland (Diet, of Pract. Med., Art. Croup) describes spas- 
modic croup as a variety or modification of true or membranous croup. 
He supposes that the modifications of true croup are attributable to 
"the particular part of the air-passages chiefly affected, to the temper- 
ament and habit of body of the patient, and the intensity of the causes.'^ 
It seems to us, however, that these views as to the nature of the two 
diseases are not correct, and we are induced by personal observation 
to regard them as distinct affections, which may, in the great majority 
of cases, be distinguished from each other at a very early stage, by a 
careful observer. The comparative fatality of the two diseases alone 
is sufficient to establish a wide difference between them. Thus, of 35 
cases of the pseudo-membranous form that we have seen, 16 died ; while 
of considerably more than 200 cases of the spasmodic form that we have 
seen, not one has been fatal. M. Guersent states that of ten cases of 
the former disease, scarcely two escape; while of upwards of a hun- 
dred of the latter that he has seen, not a single one was fatal. (Diet, de 
Med., t. ix, p. 365.) 



76 SPASMODIC SIMPLE LARYNGITIS. 

The different effects of treatment in the two affections also point to 
a Avide difference in their nature. True croup is almost inevitably 
fatal, unless attacked at an earlj- period by energetic remedies, while 
the mild spasmodic form seldom resists the exhibition of an emetic, a 
warm bath, or of nauseating doses of ipecacuanha or antimony; and 
the severe form, though of a most threatening appearance, almost 
always yields to the proper employment of very moderate local deple- 
tion, aided by the use of expectorants, emetics, opiates, and correct hy- 
gienic means. When we add to these circumstances, the differences in 
the anatomical alterations in the two diseases, the difference in the 
mode of invasion, in the cough, voice, cry, fever, duration of the at- 
tack, and state of the constitution, all of which will be carefully de- 
scribed in the remarks on diagnosis, we do not see how we can resist 
the conclusion that the}^ are two distinct disorders, and not, as was 
formerly generally asserted by English writers, degrees or modifica- 
tions of the same. 

We believe, therefore, that mild spasmodic laryngitis is a disease 
consisting in slight catarrhal inflammation of the mucous membrane of 
the huynx, attended with violent spasmodic contraction of that organ, 
or, as that condition has been called of late, laryngismus. The spasm 
of the lar^^ngeal sphincter seems to be the result of a disordered action 
of the excito-molor innervation of the part, the irritant, which is 
productive of the morbid innervation, being, in all probability, the in- 
flammation of the laryngeal mucous membrane, which has been already 
stated to constitute one element of the malady. The nervous element 
predominates in the early part of the attack, but towards the conclu- 
sion, the spasmodic symptoms disappear entirely, and we have left 
only those which depend on the local tissue-changes. 

In sevewe cases of the disease we have the same element of laryngeal 
spasm, or laryngismus, coincident with, and produced by, a much more 
intense and dangerous inflammation of the mucous membrane of the 
part than exists in the mild form. 

Diagnosis. — Unquestionably the disease with which spasmodic laryn- 
gitis is most likely to be confounded is pseudo-membranous laryngitis, 
or true croup. There is very little difficulty, however, in distinguish- 
ing the mild form of spasmodic croup from true croup, whilst in regard 
to the severe form, it may be safely stated, that the distinction cannot, 
in some cases, be made with positive certainty, except by watching the 
course of the sickness. 

Mild cases of spasmodic croup may be distinguished from membran- 
ous croup b}' a comparison of the different symptoms as they arise. 
The most important of these are: the invasion, in one sudden and 
almost invariably in the evening or night, in the other slow and creep- 
ing, the paroxysm first occurring indifferently day or night; the cough, 
in one hoarse and boisterous, in the other hoarse and frequent at first, 
but rare and smothered towards the end; the voice, in one hoarse, but 
never scarcely whispering, and if so, only during the height of the par- 
oxysm, in the other hoarse at first, and soon permanently whispering 



DIAGNOSIl 



77 



or entirely lost; the cry, in one hoarse and stridulous only at the mo- 
ment of the paroxysm, in the other permanently so; the respiration, 
in one stridulous and difficult only during the paroxysm, and in the 
interval perfectly natural, in the other, at first natural, becoming by 
degrees permanently stridulous, and attended by the most violent 
dyspncea, with remarkable prolongation of the expiration and even 
with recession of the base of the thorax in inspiration; the fever, in 
one vei-y slight and generally observed only during the nocturnal par- 
oxysm, in the other much more considerable and permanent; and 
lastly, the duration, in one seldom more than two or three days, in 
the other rarely less than six, and very often eight or ten days. M. 
Trousseau states that the hoarse-sounding croiipal cough is not a sign of 
the presence of exudation in the larynx, but rather of its absence; 
but, "when the cough, croupal at first, becomes less and less frequent, 
and ends with being nearly insonorous wnth suffocation, there is true 
croup, that is to say, with plastic exudation in the larynx." This is 
precisely our own experience. The rare, insonorous cough of M. Trous- 
seau is the condition which we have expressed by the terra smothered. 
In order to render the diagnosis still clearer, we add the following 
table, which is altered from one given by MM. Eilliet afid Barthez: 



MILD SPASMODIC LARYNGITIS. 

Begins with coryza and hoarse cough, 
or more frequently with a sudden attack 
of sutFocation in the night. Fauces nat- 
ural, or merely slight redness, as in sim- 
ple angina. 



After the paroxysm, the child seems 
well, the fever disappears, or is very 
slight. Voice natural, or only slightly 
hoarse ; not whispering. 

If the paroxysm returns, it is during 
the following night, and it is less severe; 
the hoarseness disappears ; the cough be- 
comes loose and catarrhal. 

Duration seldom more than three days. 



Very rarely fatal. 



PSEUDO-MEMBRANOUS LARYNGITIS. 

In epidemic form, begins as pseudo- 
membranous angina. In sporadic form, 
invasion of slight hoarseness for a d.-iy or 
two. There is fever, increase of the 
hoarseness, with hoarse, croupal cough ; 
in most of the cases, pharyngeal exuda- 
tion, and a little later, paroxysms of suf- 
focation. 

The fever continues ; stridulous respi- 
ration ; prolonged and difficult expira- 
tion; recession of base of thorax during 
inspiration ; cough hoarse and smothered ; 
voice hoarse and whispering. 

The dyspnoea and suffocation increase; 
the voice and cough are smothered or ex- 
tinguished ; stridulous respiration per- 
sists. 

Duration seldom less than five or six 
days. The hoarseness continues for sev- 
eral weeks. 

Fatal in the majority of the cases. 



The only real difficulty in the diagnosis is the distinction between 
the grave form and pseudo-membranous laryngitis or true croup un- 
connected with angina; and this, it w^ould appear from all evidence, 
cannot in some cases be made with absolute certa nty. The only cer- 
tain and indubitable sign by which to distinguish them is the presence 
of false membranes in the expectoration. The existence of this symp- 
tom is proof positive of pseudo-membranous disease, but its absence is 



78 SPASMODIC SIMPLE LARYNGITIS. 

no proof that the case must be one of simple inflammation; for, even 
though the membrane has been exuded in large quantities within the 
larynx, it is not alvva3^s thrown off by the effort of coughing or vomit- 
ing. To show the difficulty of the diagnosis, w^e will cite the case 
quoted by M. Yalleix {loc. cit., t. i, p. 211) from M. Hache, of a child 
supposed to be laboring under true croup, w^ho was sent to the Chil- 
dren's Hospital in Paris, in order to have the operation of tracheotomy 
performed. The absence of false membrane in the expectoration, and 
a slight remainder of clearness in the voice, occasioned the suspension 
of the operation. The child died, and no pseudo-membrane whatever 
w^as found in the larynx. The only lesions were moderate redness of 
the mucous membrane, without tumefaction, and without narrowing 
of the glottis; so that the fatal termination must be ascribed to spas- 
modic constriction of the glottis, or to tumefaction of that part which 
had disappeared after death. 

Nevertheless, though the diagnosis is difficult, it can almost always 
be made out with certainty by attention to the following points. The 
pseudo-membranous form of the disease is usually preceded or accom- 
panied by the presence of false membranes in the fauces, which is not 
the case in spasmodic simple laryngitis; the symptoms of invasion of 
the former disease are less acute than those of the latter, the fever 
being less violent, and the restlessness and irritability less marked, 
than is usual in the simple affection, in which the general symptoms 
are decided from the first. The hoarseness of the voice and cough 
follow a different course in the two diseases; the progress of these 
symptoms being slow and gradual in the membranous, and much more 
rapid in the severe spasmodic form. The fever is marked throughout 
the attack in the severe spasmodic disease, whilst in the other form it 
seldom reaches a high degree of intensity. Lastly, the presence of 
portions of false membrane in the expectoration, in connection with 
the larj'ngeal symptoms, affords positive evidence of the existence of 
true croup. 

Of the characters just enumerated as likely to aid us in distinguish- 
ing between severe spasmodic and true or membranous croup, w^e wish 
to call the reader's attention in greater detail to two — the condition of 
the voice, and the stridulous respiration. The former is, we have no 
doubt, much the most important single symptom. In membranous 
croup, the voice begins by being hoarse, but soon becomes weak, so 
that after the disease has lasted three or four days, it changes from 
hoarse to whispering; it becomes, in fact, suppressed. In severe spas- 
modic croup, the voice is hoarse at first, and becomes more so as the 
disease goes on, but it very rarely becomes whispering as in true croup, 
but almost always retains a good volume, so that when urged the child 
can speak out loudly. Now this is never the case in the membranous 
disease, for, as the fibrinous exudation is deposited on the vocal cords 
and in the ventricles of the larynx, it suspends almost entirely the 
functions of those parts, and the voice is more or less completely sup- 



PKOGNOSIS. 79 

pressed. The remarks just made in regard to the voice will apply also 
to the cry, which' should be carefully studied in young infants. 

The second very important symptom is the stridor. This is, as might 
be expected, more marked in all its features in true than in false croup, 
since in the former it depends on a permanent and considerable obsta- 
cle to the passage of the air through the larynx. That tube is, in fact, 
completely coated over upon its internal surface, with a more or less 
thick false membrane, which reduces materially its calibre, and im- 
pedes to a greater extent the passage of air, than does the mere in- 
flammatory turgescence and swelling of the mucous membrane of the 
organ in severe spasmodic croup. On this account, therefore, the stri- 
dor in the respiration is louder, shriller, more persistent, more marked 
in the expiration, and attended with greater effort of the respiratory 
muscles to overcome the obstacle to the passage of the air in membra- 
nous than in severe spasmodic croup. We may add that there is some- 
thing very peculiar in the cough in true croup. When the membrane 
has come to cover the interior of the larynx, the cough is very dis- 
tinctive; it has a sound which we can describe only by saying that it 
alwaj's reminds us of the sneezing of a young kitten. This we have 
never heard in catarrhal croup, no matter how severe. 

To conclude, there is in membranous croup a slow, steady, and unre- 
lenting progression of the symptoms, which is not observed in the spas- 
modic disease. From hour to hour, from day to day, we can perceive, 
so to speak, from the gradual and steady march of the disease, that a 
foreign body in the form of a fibrinous moulding is being spread slowly 
over the cavity of the larynx. In severe spasmodic croup, on the con- 
trary, the course of the symj^toms is less regular; paroxysnis of suffo- 
cation occur as in true croup, but when these are over, the child is 
often quite comfortable; the symptoms indicating a much less consider- 
able permanent mechanical obstruction than in the other affection. 

Spasmodic laryngitis has been mistaken also for laryngismus stridu- 
lus. The manner in which it is to be distinguished, will be described 
in the article on that disease. 

Prognosis. — Spasmodic catarrhal laryngitis is very rarely a fatal 
disease. Of its two forms, there can be no doubt that the severe is 
much more dangerous than the mild, since in the former the patient 
labors under acute inflammation of the larynx, 'as well as under spasm 
of that organ ; whilst, in the latter, the amount of inflammation is so 
very slight as to be of little or no consequence, were it not associated 
w^ith the laryngismus, which gives to the disorder its most character- 
istic features. 

Of 109 cases of the disease of which we have kept an accurate record, 
none proved fatal, though 28 of these were of the grave form. We may 
state, also, that we have seen at least 100 more cases, of which we have 
no written account, in none of which was there a fatal termination. 
We have, therefore, never seen a case of croup without false membrane 
prove fatal. That it does sometimes end 'unfavorably, however, can- 
not for a moment be questioned. There are various examples of the 



80 SPASMODIC SIMPLE LAEYNGITIS. 

kind scattered through the medical journals. MM. Eilliet and Barthez 
quote, in proof of this, two cases from the work of ilurine, in one of 
which an autops}^ was made, and no false membrane discovered. Cop- 
land (loc. cit.) remarks, that in the few cases of the more purely spas- 
modic forms that he has had an opportunity of examining, an adhesive 
glairy fluid with patches of vascularity on the epiglottis and larj^nx, 
and a similar fluid in the large bronchi, were the only alterations ob- 
served. 

Great imminence of danger in any case is shown by a high intensity 
of tbe stridulous sound, especially as heard in the expiration; by great 
severity of the dyspnoea or suffocation; by permanently whispering 
voice; by lividity or extreme paleness of the face; by smallness and 
rapidity of the pulse; by coldness of the extremities; and by delirium 
or convulsions. 

Treatment. — M. Guersent (loc. cit., pp. 367, 368) states that demul- 
cent and mucilaginous drinks, with stimulating hand-baths and foot- 
baths, are the principal means that ought to be employed in the treat- 
ment of spasmodic laryngitis, or pseudo-croup. He proscribes the use 
of emetics and leeches as unnecessary in most cases, and is of opinion 
that they have come into generaj use, in the management of the dis- 
ease, in consequence of its having been generally confounded with true 
croup. In a paper on croup, by the late Dr. Charles D. Meigs (3Ied. 
Exam., vol.i, p. 398), may be found the following statement in regard to 
the spasmodic variety-: "The croup sound often ceases entirely, and 
never returns after the exhibition of a small quantity of ipecacuanha, 
or any other emetic substance, even when no emesis is produced." He 
saj'S in another place, that "a foot-bath with mustard, and an emetic 
of ipecacuanha, is in general all that is necessary for the cure." 

In. giving our own experience in regard to the treatment of this dis- 
ease, we shall speak first exclusively of the mild, and then of the severe 
form, since the measures proper and necessary in the one, are very dif- 
ferent from those called for in the other. 

Treatment of the Mild Form — Emetics. — The great majorit}^ of 
cases will recover perfectl}^ well under the use of emetics employed 
alone, or in combination with warm baths and revulsives. Of late years 
we have often succeeded in warding off the slight attack, where there 
has been good reason to expect it, by the administration of an opiate 
with syrup of ipecacuanha, at bedtime (early in the evening). At two 
years of age, three or four dro]DS of laudanum, with ten to twenty drops 
(according to the gastric susceptibility) of syrup of ipecacuanha; at 
three or four j-ears, five drops of laudanum with twenty of the ij^ecac- 
uanha, are about the proper doses. Even when the child has had one 
attack early in the night, the use of the opiate is most successful, after 
vomiting, in preventing the usual return towards morning. If the phy- 
sician is not called until the day after the first attack, this treatment 
is excellent in the evening of the second day. In cases attended with 
violent dyspnoea, hoarse cough, and loud stridulous respiration, the 
emetic should be given until it produces a full effect. In milder cases, 



TREATMENT. 81 

t 

in Nvbicb there is merely load croiipal cough, with an occasional stridu- 
lous sound, nauseating doses alone will generally suffice. The most 
suitable emetic is, as a general rule, ipecacuanha. The best prepara- 
tion for children is the syrup, of which from twenty to thirty drops 
may be given to those two years of age, to be repeated ever}^ ten or 
twenty minutes until vomiting is produced, or until the paroxysm is 
relieved. In very sudden cases, the Syrupus Scillse Compositus, which 
is more active in its effects in consequence of the tartar emetic which 
it contains, might be preferable ; -about twenty drops of this may be 
given, and repeated every ten or fifteen minutes, until vomiting or the 
resolution of the paroxysm is obtained; but, in its employment, care 
should always be observed not to continue it for too long a time, lest it 
produce the injurious effects of tartar emetic. Of late years we have 
almost entirely abandoned the use of this latter emetic, as we succeed 
perfectly well with the ipecacuanha, and dislike more and more the 
antimonial preparation in children. When the dyspnoea is very urgent, 
or when other means fail to produce emesis, we have found nothing so 
effectual as powdered alum, in doses of a teaspoonful mixed with honey 
or molasses. (See Treatment of 'pseudo-memhranous laryngitis?) 

A simple and good method of treating the paroxysm is that recom- 
mended by Dr. Charles D. Meigs, in the paper referred to. It is to 
direct a small teaspoonful of powdered ipecacuanha to be diffused in a 
wineglassful of water, of which mixture doses of a teaspoonful are to 
be given every ten, fifteen, or twenty minutes, according to the urgency 
of the sj'mptoms. This is a plan of treatment often resorted to by 
parents in this community, where the disease is so common and so well 
understood^ that there are few mothers who have several children, and 
who have had some little experience, who do not know how to treat a 
nocturnal attack of mild spasmodic laryngitis. 

A very simple and efficient mode of treating the paroxysm, w^hich 
was first recommended by Graves, consists in gently pressing a sponge 
soaked in warm w^ater under the chin and to the front of the neck. 
This may be repeated every ten or fifteen minutes, and under its influ- 
ence the croupy symptoms will often promptly subside without the use 
of an emetic. 

After the paroxysm is relieved, it is a good plan to direct five or ten 
drops of the ipecacuanha syrup to be given every two or three hours 
during the following day; or, if the child seems perfectly well in the 
morning, we may begin with these doses in the middle of the day, and 
continue them until bedtime. By this method, the recurrence of the 
paroxysm during the second night may, we think, often be prevented, 
and the cough is rendered free and loose much sooner than when the 
disorder is left to pursue its natural course. Moreover, the child ought 
to be kept in the house during the next tw^o or three days, or until the 
cough is thoroughly loose and easy. If the child be at all a delicate 
one. or one in whom the disorder is prone to be obstinate, there is no 
plan so good as to make it sit or lie quietly in bed, sufficiently covered, 

6 



82 SPASMODIC SIMPLE LARYNGITIS. 

with a large abundance of playthings, or with a kind nurse to read to 
and amuse it for two or three days. 

Baths. — The warm bath is a very prompt and useful remedy in the 
disease. In all very violent cases, it ought to be resorted to immedi- 
ately. It should be used also whenever the emetic fails to relieve the 
urgency of the symptoms, and in cases attendant with much disturb- 
ance of the circulation. The temperature of the water ought to be 
about 95"^ Fahrenheit, when the child is first immersed, to be raised 
gradually by the addition of hot water, to 100° or 102°. The child 
may remain in the bath from ten to twenty minutes. 

Revulsives. — The only revulsives that it can be necessary to employ 
are mustard foot-baths or mustard poultices applied to the interscapu- 
lar space; and even these are often needless if the emetic be given. 
Blisters, which are recommended by some of the French writers, can 
only be proper in rare cases of the grave form. 

Furgatives are required when constipation is present, or when there 
is so much fever on the second or third day, as to show a considerable 
amount of laryngeal inflammation. Under the latter circumstances 
some mild remedy of this class may be resorted to with a view to its 
evacuant effect. We have never had occasion to employ any of the 
mercurials^ and believe them to be unnecessary. 

Opium is exceedingly beneficial when the emetic, nauseant, or warm 
bath has failed to relieve entirely, and when a troublesome eroupal 
cough continues after the sj^asm has been overcome. Laudanum, pare- 
goric, or solution of morphia, in combination with syrup of ipecacuanha 
or Dover's powder alone, are the most suitable preparations. It is a 
very good plan to give the child a moderately full dose of the opiate, 
with ipecacuanha, after the violence of the paroxysm has subsided. It 
puts the child to sleep, promotes perspiration, softens the cough, and 
tends to prevent the return of the spasm. Eepeated once or twice early 
in the second night after the first attack, we believe it often assists 
materially to avert the recurring nocturnal paroxysm. 

Treatment or the Severe Form. — This form of spasmodic larj^n- 
gitis requires more active measures than the mild form of the disease. 

In some of the former editions of this work, bloodletting was recom- 
mended when the disorder occurred in robust and vigorous children, 
and a record was given of the employment of venesection in seven out 
of twenty-three cases, all of which recovered. Since that report we 
have learned that depletion is less necessary than we formerly sup- 
posed, and, as we can still say that we have never yet seen a fatal case 
of spasmodic croup, either simple or severe, it is fair to conclude that 
the disease can be safely managed without a resort to this more vio- 
lent measure. Still, it is but proper to state, that should a case occur| 
to us in a strong and healthy child, in which the breathing should be- 
come so much obstructed as to cause deep and alarming venous stasis,! 
and in which these symptoms resisted the more simple means we now 
employ, we should not hesitate again, as in former years, to employ a 



TREATMENT. 83 

venesectioD to the extent of four ounces at the age of foar or five years, 
or a leeching to the same amount. 

Our favorite remedies of late years have been emetics, opiates, salines, 
and the sulphurated antimony of the recent Pharmacopoeia. When the 
patient is a vigorous child, and over a year old, we generally employ 
the following combination : 

R. — Antimon. Sulphurat., gr. j. 

Pulv. Doveri, ........ gr. iij. 

Sacch. Alb., ........ gr. xij. 

M. et div. in chart, xij. 

Of these powders one may be given every two, three, or four hours, 
care being taken to suspend the antimony when it produces any of the 
peculiar distress or general prostration to be described in the article on 
pneumonia. In such a case, we use the following combination : 



R.— Potass. Citrat., 


• 3J- 


Syrup Ipecacuanhse, .... 


• • ^m- 


Tr. Opii Deodorat., .... 


. gtt. xij. 


Syrup Simp., 


• . fsij- 


Aq., 


. f^iss.-M 



Dose for a child two years old, a teaspoonful every two hours. 

In older children, both the potash and opiate may be doubled. In 
all these cases an emetic ought to be given once, or two or three times 
in twenty-four hours, when the dyspnoea and stridor become very se- 
vere ; and in about an hour after its operation, the saline dose should 
be resumed. Of course, if decided drowsiness supervene from the 
opiate, the doses must be given at longer intervals. The emetic treat- 
ment is not so essential as in true croup, where it is so useful in caus- 
ing the rejection of the false membrane which obstructs the larynx. 
Yet it is exceedingly useful, and often indispensable, in assisting to 
expel the viscid mucus secreted within the larynx, and in relaxing, for 
a time at least, the spasmodic constriction of the glottis, which plays 
a most important part in the production of the distressing dyspnoea 
and suffocation of the disease. They act probably also by lessening 
immediately, or through their action on the circulatory and nervous 
sj'Stems, the inflammation of the larynx. For their choice and mode 
of administration, the reader is referred to the article on true croup. 

Purgatives are required merely to keep the bowels soluble; they 
should be repeated as may be necessary throughout the disease. If 
the bowels are moved every day or every other day spontaneously, 
there is no use in giving them at all. The most suitable are castor oil, 
rhubarb, or magnesia, in small doses; or an enema may be given from 
time to time if the child does not resist its application. 

Expectorants are useful after the violence of the disease has been 
moderated by more energetic remedies. They may consist of small 
doses of ipecacuanha, of antimonial wine and sweet spirits of nitre, of 
decoction of seneka, snakeroot, or of the citrate or carbonate of pot- 
ash. ^ 



84 SPASMODIC SIxMPLE LARYNGITIS. 

Opiates are necessary, and are serviceable, as has already been stated, 
in calming excessive restlessness, and in allaying the violence of the 
suffocative attacks, which depend, in good part, on spasm of the glot- 
tis. The most suitable are Dover's powder or some other preparation 
of opium, or small doses of belladonna, or hyoseyamus. 

Belladonna would seem, from its power to relax the sphincters, and 
from its excellent effects in hooping-cough, to be indicated in this dis- 
ease, but we have succeeded so well with opium that we have not often 
used belladonna. Probably a combination of the two would be found 
beneficial. 

A warm hath at 97° or 98°, employed once or twice a day, and con- 
tinued for a period of ten or fifteen minutes, often assists greatly in 
lessening the sufferings of the child, in calming restlessness, and in 
moderating the heat of skin, and violence of the circulation, w^hen the 
latter symptoms are strongly marked. The same effects may often bo 
obtained by the use of counter-irritants, as sinapisms, mustard poul- 
tices, mustard foot-baths, &c. Blisters are of doubtful propriety in any 
cases. 

Hygienic Treatment. — In either form of the disease the child should 
be placed for the time in a warm room, and warmly clothed. If old 
enough, it ought to be kept as much. as j30ssible in bed during the par- 
oxysm. If so young as to prefer the lap of the nurse, it should be 
clothed in a long loose wrapper in addition to its usual night-dress. 
It is very important to confine the child during the whole term of the 
acute period in the bed, if it is over three or four years old, and in the 
crib or lap if it be younger. Even after the cessation of the acute con- 
dition, it ought to be kept in the house for a few days, in order to 
make .sure of the convalescence. The diet must be simple and of easy 
digestion, so long as there is any disposition to recurrence of the dis- 
ease. It may consist of pre^^arations of milk, of bread, rice, or of thin 
chicken or mutton water. Meat and most vegetables had better be 
avoided until the convalescence is fairly established. 

Prophylactic Treatment. — It is certain that much may be done by 
a wise attention to })hysical education, to prevent attacks of the disease 
in children who show a liability to it. We would strongly recommend, 
with this view, attention to the following advice given by M. Guersent, 
who says (loc. cit., p. 381) : " It is possible, to a certain extent, to pre- 
vent attacks of pseudo croup, if we fortify the constitutions of children, 
by exposing them well-clothed to a dry and elastic atmosphere, par- 
ticularly if they can be kept in constant movement. But of all the 
precautions which have been found unquestionably advantageous, that 
which seems most useful is to make them sleep in well-ventilated, dry, 
carefully closed chambers, having a southern exposure, and always 
without fire. We have several times been convinced of the utility of 
this habit in families the children of which were subject to this kind 
of catarrh." 

There can be no doubt that the style of dress used for children in 
this country, must occasion many and repeated attacks of croup which 



TREATMENT. 85 

might just as well have been avoided. The custom is to dress children 
between the ages of one and four or five years, in such a way as to 
expose to the air the whole of the neck and the upper half of the 
thorax (for the dresses are made so low and loose at the shoulders, as 
to leave the upper part of the chest virtually uncovered). The arms 
are left bare, as are also the legs from the knee, or above the knee, to 
the ankle, so that very nearly half of the cutaneous surface is without 
covering, and this, too, in the very same rooms and temperature in 
which sit the parents with the body and limbs warmly clothed to resist 
our climate, at all seasons changeable and uncertain, and, in the winter, 
very cold. We are perfectly well convinced that this faulty and unrea- 
sonable system of dress, which is chosen because it is the fashion, or in 
order to harden the child, who, however, invariably puts on warm 
clothing when it comes to years of discretion, will explain in part the 
enormously greater frequency in children than- in adults, of the various 
diseases of the air-passages and lungs produced by cold. 

One of the most important means of prevention, therefore, is the 
adoption of a suitable dress. In winter this should consist of one that 
shall cover the body completely. If the child be at all delicate, it ought 
to wear next to the skin a woollen jacket with long sleeves, and cover- 
ing the chest to the neck. Over this should be put a long-sleeved stout 
muslin dress, or one of some light woollen material, made in the same 
style. In young children, the stockings ought to be of wool, and should 
reach to the knees; in older ones, they may be shorter, but the legs 
should be covered with drawers made of canton flannel, of thick cotton 
stuff, or of light woollen flannel. To show the influence of dress, Dr. 
Eberle mentions the fact that in the country, and especially amongst 
the Germans, who cover the neck and breast, croup is a very rare dis- 
ease. During a practice of six years amongst that class of people, he 
met with only one case of the disease. 

When the liability to the disease continues after the completion of 
the first dentition, we have found the daily use of the cold bath, in con- 
nection always -with warm clothing, most useful in preventing the 
attacks. The bath must be commenced with in the summer, and per- 
severed in through the following winter. The water, after the cold 
weather begins, should be drawn in the evening, allowed to stand all 
night in a room in which there is a fire through the day, and made 
use of on the following day. Prepared in this way, we have found the 
water in the morning at a temperature of between 50° and 60° F. The 
child ought to be kept in the water only half a minute or a minute, 
then well rubbed, and dressed immediately. 

When the child is pale, weak, and feeble, and unable to bear expos- 
ure to the outer air, it may generally be restored to much better health 
by careful attention to diet, and by the steady and long-continued use 
of some tonic remedy. The diet ought to consist of bread and milk, 
and of meat and the simpler vegetables, as potatoes and rice. The 
tonics most generally suitable are quinine or iron. Of the quinine a 
grain may be given in pill or solution, twice or three times a day; 



86 PSEUDO-MEMBRANOUS LARYNGITIS. 

while at dinner or lunch, or at both, the child should be made to drink 
from a dessert to a tablespoonful of port wine, mixed with water. This 
method ought to be steadily persevered in for from three to six weeks 
or longer. If quinine be objectionable for any reason, iron must be 
substituted. The best preparations are the iodide or the metallic iron. 



AETICLE III. 

PSEUDO-MEMBRANOUS LARYNGITIS, OR MEMBRANOUS OR TRUE CROUP. 

Definition and Synonyms. — Fseudo-membranous laryngitis is an 
acute inflammation of the mucous membrane of the larynx, attended 
with the exudation of false membrane. 

It is the croup of the French writers, while, in this countrj^, it is 
called by the various names of slow, creeping, true, membranous or 
inflammatory. The term given above seems most suitable, as expres- 
sive of the real nature and seat of the disease, and we shall, therefore, 
make use of it in contradistinction to that of spasmodic laryngitis or 
spasmodic or false croup, which is a much more common and less dan- 
gerous aifection. 

Nature and Eelations. — By most authorities, true croup is regarded 
as an idiopathic primary inflammation, presenting the unusual result 
of pseudo-membranous exudation, and differing thus from diphtheritic 
croup, which is a mere complication in the course of a constitutional 
disease, depending upon the extension of the false membrane from the 
fauces into the larynx. 

The considerations upon which this distinction is based may be briefly 
stated as follows: that true croup is a disease peculiar to childhood, and 
that many of its peculiarities are to be explained by reference to the 
development of the larynx at that period; that it is not connected with 
an}^ special alteration of the blood crasis ; that it nearly always com- 
mences in the larynx, and, though it may pass downwards into the 
trachea, never passes upwards into the pharynx; and finally, that it 
does not present the complications of diphtheria, such as albuminuria 
and pseudo-membranous exudation on abraded surfaces, nor its char- 
acteristic paralytic sequelae. 

So far as the mere anatomical conditions are concerned, it is gener- 
ally conceded that there is no essential difl'erence between primarj^ 
croup and pseudo-membranous croup occurring in the course of diph- 
theria. The attempt was made by M. Isambert to base a distinction 
between the two affections upon the ulcerated condition of the mucous 
membrane of the larynx in diphtheritic croup, but West has met with 
similar ulceration in cases of primary croup, though somewhat less 
frequently than in the secondary diphtheritic form. 



NATURE AND RELATIONS. 87 

Bat fnvther, our personal experience constrains us to state that the 
differences between the two forms of membranous croup above enumer- 
ated, have not seemed to us sufficiently marked and constant to posi- 
tively establish their essential diversity; and that it is our decided 
opinion that the vast majority' of the cases usually termed pseudo- 
membranous laryngitis are in reality instances of primary laryngeal 
diphtheria, in which the constitutional symptoms are not grave, and 
where the faucial deposit has been very slight and perhaps even over- 
looked. 

We are led to this conviction especially by the repeated observation 
of cases in private practice, where we have been summoned upon the 
first symptoms of indisposition, and have found a trifling amount of 
membranous exudation on the fauces, which, in a day or two, had 
disappeared, while the symptoms of croup supervened. 

Apart from their sporadic occurrence, we confess that we are alto- 
gether unable to detect any difference between such cases and the cases 
of so-called primary laryngeal diphtheria, frequently met with in epi- 
demics of diphtheria, where the angina is but trifling, and is rapidly 
followed by pseudo-membranous formation in the larynx. 

It is true that the primary sporadic form of croup we are now dis- 
cussing occurs more exclusively in children than does the more fully 
developed form of diphtheria ; but it must be remembered that in child- 
hood there seems to be a peculiar tendency for the larynx to become 
involved in the course of diphtheria, and also that a comparatively 
trifling amount of membranous exudation in a child's larynx will pro- 
duce grave symptoms of obstruction. 

It is also true that these sporadic cases are rarely attended with al- 
buminuria or followed by paralytic sequelae; but when we consider the 
remarkable variations in the frequency of these conditions in different 
epidemics of diphtheria, it is not inconsistent that they should be 
usuall}^ absent in mild sporadic cases. 

It is not our intention in the above remarks to deny the possibility 
of pseudo-membranous laryngitis occurring as a purely primary idio- 
pathic affection, and we have consequently treated of it as a special 
disease, apart from the brief notice of it we have given in the article 
on diphtheria. 

But the considerations which we wish to impress deeply upon the 
mind of the reader are, that in the vast majority of cases of true croup 
careful examination of the throat at an earlj^ period of the attack will 
show the presence of exudation on the tonsils or pharynx; and that, 
consequently, whenever a child is taken sick with even the most tri- 
fling croupy symptoms, the throat should be immediately and repeat- 
edly examined, and, if any membranous exudation be detected, the 
case should be regarded as probably one of membranous croup, a most 
guarded prognosis accordingly^ given, and the most careful treatment 
immediately instituted. 



88 PSEUDO-MEMBRANOUS LARYNGITIS. 

Frequency. — The mortality from this disease is in all years consider- 
able, as will be seen from the subjoined table: 









Mortality 






Mortality 


Total Mortality 


Years. from Croup. from Diphtheria. 


less Stillborn. 


1838, ... 101 ... . . 


4,118 


1839, 






83 







4,765 


1840, 
1841, 






79 
100 










4,593 
5,456 


1842, 
1843, 






137 
129 










. 5,558 
5,155 


1844, 






179 









5,187 


1845, 






176 









5,882 


1846, 






111 









6,944 


1847, 
1848, 






121 
177 










6,881 
. 7,268 


1849, 






130 









. 8,989 


1850, 






151 









8,034 


1851, 






180 









8,374 


1852, 






208 









9,745 


1853, 






303 









9,184 


1854, 






304 









11,280 


1855, 
1856, 






265 

268 










9,91)6 
11,720 


1857, 






256 









10,331 


1858, 






292 






. . 


10,162 


1859, 






312 









9,084 


1860, 






354 






307 


10,849 


1861, 
1862, 






304 
258 






502 
325 


. 13,838 
14,386 


1863, 






443 






.434 


. 15,045 


1864, 






455 






. 357 


. 16,794 


1865, 






350 






260 


16,453 


1866, 






239 






192 


. 16,005 


1867, 






185 






118 


13,153 


1868, 






206 






118 


. 13,949 



It is difficult to estimate the number of deaths due to this affection 
during the last nine years, since diphtheria has made its appearance 
in the mortality lists of the city, as many cases of diphtheritic croup 
have unquestionably been returned as mere pseudo-membranous laryn- 
gitis. 

True croup is, however, rare in comparison witli false croup, since 
while we have seen but 35 cases of pseudo-membranous laryngitis, we 
have met with upwards of 200 of the catarrhal form. In the following 
remarks, and in those on the causes of croup, we refer the reader also 
to the table in the article on diphtheria^ showing the comparative 
monthly and annual mortalities from these two diseases. 

From a glance at the accompanying table, it will be seen that since 
the prevalence of diphtheria, the mortality from croup has not increased 
disproportionately to the increase in general mortality; and that, dur- 
ing the last three years, in which there was a marked decrease in gen- 
eral mortality, despite the occurrence of over 100 deaths from diphthe- 



PREDISPOSING CAUSES. , 89 

ria in each year, the mortalitj^frora cronp has also fallen even below the 
average sustained for many years previous to the appearance of diph- 
theria in the mortality lists. No chans^e whatever has occurred in the 
t^'pe of this disease during the past ten years, for the experience of one 
of us for a number of years before the term diphtheria came into use 
and appeared in the mortality returns of this city, enables ns to attest 
the fact that pseudo-membranous laryngitis, both of the primary and 
of the more grave diphtheritic form, occurred then precisely as it does 
now. 

Predisposing Causes — Age. — The disease is far most frequent be- 
tween the close of the first and fifth years. Thus of 2136 fatal cases 
reported in this city during the 7 years from 1862-68, 301 were under 
1 year of age; 571 between 1 and 2 years; 951 between 2 and 5 years; 
or, 1522 between 1 and 5 years; and 236 between 5 and 10 years; 
leaving but 77 cases as occurring after the latter period of life. 

Of the 35 cases that we have seen, 28 occurred between 2 and 7 3"ears 
of age. while of the remaining 7, 1 occurred at the age of 18 months, 1 
at that of 19 months, 1 at 7* years, 2 at 11 years, and 1 each at HI and 
121 years. 

Sex cannot be said to exercise any decided influence upon the fre- 
quency of the disease. Thus of the above 2136 cases, 1115 occurred in 
males, 1021 in females. 

Constitution. — A feeble and delicate constitution is thought by some 
to be a powerful predisposing cause, but this is at least very doubtful. 

Of the 35 cases referred to, 26 occurred in healthy vigorous children, 
while the remaining 9 occurred in children who, though neither very 
weak nor very sickly, presented a rather delicate appearance. 

Season exerts a very powerful influence upon the development of 
croup. Thus the mortality from it attains its maximum during the 
months of November, December, and January, during which quarter 
about four times as many deaths occur from croup as during the months 
of June. July, and August. It is, however, comparatively frequent from 
October to March inclusive. 

The relation between the mortality from ci'oup and the temperature 
appears to be a definite and quite constant one, since, as will be seen by 
referring to the table in the article on diphtheria, with the single ex- 
ception of February, the mean monthly temperature and the mean 
monthly mortality from croup rise and fall together throughout the 
entire year. 

The exciting causes are but little understood. The only ones which 
seem to have been ascertained with any certainty, are the application 
of irritating agents to the laryngeal mucous membrane, and exposure 
to cold, and even these are questioned by the most accurate observers. 
In none of the cases that we have seen could the exciting cause be even 
suspected. 

Second Attacks of membranous croup, though rare, are mentioned 
as occurring by several authors; and, in our remarks on tracheotomy, 
we quote from Millard an allusion to five cases, in each of which the 



90 PSEUDO-MEMBRANOUS LARYNGITIS. 

Operation was twice successfully performed for successive attacks of 
this disease. 

We have ourselves met with two instances in which second attacks 
occurred. One was a girl, who had her first attack at the age of 11 J 
years, and her second at the age of 12J, and recovered from both with- 
out the operation. The second patient was a boy, who had his first 
attack, a very severe one, but from which he recovered without trache- 
otomy, at the age of 5J years; and his second attack, which is fully de- 
tailed at the end of the article on tracheotomy (Case 1), at the age of 
7i years. 

Anatomical Lesions. — The false membrane may cover the whole 
mucous membrane of the larynx, and extend into the pharynx, trachea, 
and bronchia; or it may be confined to the larynx, either forming a 
complete lining to the cavity of that organ, or consisting merely of 
patches of various sizes, with intervals of mucous membrane destitute 
of exudation. 

It is, in the first place, important, to ascertain the proportion of cases 
in which the deposit extends into the bronchia, and those in which it 
remains limited to the larynx, or larynx and trachea, as the determina- 
tion of this point has some bearing upon the question of the propriety 
of the operation of tracheotomy. It appears from a table given by M. 
Guersent {Diet, de 3Jedecine, t. ix, p. 346), containing the results of cases 
collected by M. Hussenot from various sources, and of autopsies made 
by M. Bretonneau, numbering in all 171, that in 78 the membrane did 
not extend beyond the trachea, and that in 42 it invaded the bronchia, 
and in 80 the condition of the bronchia was not mentioned; and in 21 
there were no false membranes; so that of 120 cases, in which the ex- 
tent of the false membrane was accurately noted, it was confined to 
the larynx and trachea in 78, and extended into the bronchia only in 
42 ; or in about one-third of the cases. This proportion is the same 
that Millard gives {Be la Tracheotomle dans le cas de Group, These de 
Paris, 1858), in his masterly memoir upon croup, after an analysis of a 
large series of cases. Our own experience, based upon 10 cases in which 
we ascertained with exactitude (by autopsy and by tracheotomy) the 
extent of the membrane, would indicate that it passed into the bronchia 
in a larger proportion of cases ; since in 5 of these 10 cases the exudation 
extended beyond the trachea. It is to be borne in mind, however, that 
the cases upon which these calculations are based have very frequently 
resulted fatally, and presented extensive formation of pseudo-membrane 
in the bronchia; and it is probable that it really exists there in other 
instances, but to a much less extent, so that recovery takes place, 
and renders it impossible to determine accurately the extent of the 
exudation. 

The proportion of cases in which the pharynx is implicated is also 
important, since it afi^ects the diagnosis of the disease, and indeed bears 
upon the question of the identity or non-identity of pseudo-membranous 
laryngitis and diphtheritic croup. 

In considering the statements of authors upon this subject, it is evi- 



ANATOMICAL LESIONS. 91 

dent thiit much of the diversity in their opinions depends upon the fact, 
that they are not in reality all referring exclusively to this particular 
aftection. Thus the assertion of M. Guersent {Diet, de Med., t. ix, p. 
339). that in nineteen-twentieths of the cases the exudation begins in 
the pharynx, is evidently to be explained on the supposition that this 
distinguished practitioner had been observing a series of cases of diph- 
theria in Avhich the exudation had extended into the larynx. MM. 
Eilliet and Barthez, on the other hand, state that a majority of the 
cases observed by themselves, and of those of M. Hache also, com- 
menced in the larynx. Dr. West also reports 11 cases of idiopathic 
croup, in only two of which was there any formation of false mem- 
brane upon the velum and tonsils. 

In 31 cases observed by ourselves, in which the condition of the throat 
was recorded, the croup followed membranous angina in 21 cases; in 5 
the disease began in tlie larynx, but was attended later with small de- 
posits upon the tonsils; and in 5 only was there no deposit on the throat 
at any time. 

The fauces and pharynx do not present any constant alterations in 
cases of croup. Frequentl}^, however, the mucous membrane is red 
and swollen, and there may be patches of membranous exudation upon 
the tonsils, velum, half-arches, or on the pharynx. These patches are 
usually thin, whitish, and may not persist more than 24 to 48 hours, 
disappearing and being succeeded by similar formations in some other 
part of the throat. 

We believe indeed that such patches of exudation will be found in 
a large proportion of cases during the first two or three days of the 
attack; and that they are not more frequently observed, chiefly be- 
cause the symptoms are usually so slight during this stage, that either 
no medical attendant is summoned, or his attention is not attracted to 
the throat. 

The most important and characteristic morbid appearances are, how- 
ever, to be found below the glottis, and consist in the presence of pseudo- 
membranous exudation, and of certain alterations in the respiratory 
mucous membrane. 

The false membrane may be limited to the larynx, or to the larynx 
and trachea; or it may extend over these parts and into the branches 
of the bronchi, even to the third and fourth division. In the larynx, 
trachea, and even the primitive bronchi, it may appear merely as 
patches of various sizes, with intervening spaces of vascular mucous 
membrane; but in the smaller air-passages it usually takes the form of 
complete tubes lining the bronchus. In some cases, such tubular casts 
may be formed continuously from the larynx down to the minute bron- 
chioles, completely lining the air-passages. It is undoubted, that in 
the more sthenic idiopathic form of membranous laryngitis, the mem- 
brane is more apt to extend deeply into the ramifications of the bronchi, 
than when it occurs as a complication of diphtheria. 

The false membrane is commonl}^ of a yellowish-white color, and 
from a fifth of a line to a line in thickness. Its consistence is gener- 



92 PSEUDO-MEiMBRANOUS LARYNGITIS. 

ally considerable, and it is usually somewhat elastic; indeed the more 
white and fibrous varieties possess a degree of firmness and toughness 
that renders it difficult to tear the membrane, or teaze it out with 
needles. It is an almost invariable rule, that the membrane lining the 
upper part of the air-passages is more white and firm than that found 
in the smaller bronchi; so that it frequently happens, that, on draw- 
ing out the firm white tubular membrane lining the larj-nx, trachea, 
and primary bronchi, it is seen to terminate in branches which grow 
progressively softer, more yellow and purulent, as they become smaller 
and smaller. 

The free surface of the pseudo-membrane is usually covered with 
puriform mucus, while the attached surface is adherent with various 
degrees of force to the mucous membrane beneath. The strength and 
closeness of these adhesions are often proportionate to the firmness 
and tougliness of the false membrane itself. In the larj^nx and tra- 
chea it is often necessary to employ a good deal of force to separate 
the exudation from the mucous membrane, and innumerable little 
fibres are seen passing from one to the other, as though they were pro- 
cesses of exudation dipping into the minute orifices of the mucous 
follicles. On the other hand, the adhesion between the exudation and 
mucous membrane is rarely close in the smaller bronchi, or in cases 
where the pseudo-membrane in the larynx and trachea is less firm and 
consistent. 

These false membranes consist, according to Hasse. mainly of fibrin 
blended with mucus in various proportions. (^Pat/i. Anaf., Syden. Soc. 
ed., p. 278.) On microscopic examination, they present a more or less 
close fibrous basis, consisting of interwoven fine fibrils, with imbedded 
cells in varying number ; these cells presenting the ordinary appear- 
ances of exudation-corpuscles, being round, granular, and containing 
from one to three small nuclei. The action of various chemical reagents 
upon them will be found detailed in the article on diphtheria. 

The mucous membrane beneath the exudation presents various shades 
of redness, or it is purplish, or even ecchj-mosed and blackish. It is also 
swollen, and may be slightly softened or friable, and has a dull excori- 
ated appearance, though actual ulceration very rarely exists. West 
mentions the occurrence of small aphthous ulcers about the edges of 
the rima glottidis and the arytenoid cartilages, as a frequent lesion in 
idiopathic croup ; but the same lesion has been observed in the diph- 
theritic form of the disease. 

There is also vascularity, though usually to a less marked degree, of 
the bronchial mucous membrane at the points where no exudation 
exists. 

The lungs present some abnormal condition in the great majority of 
cases. Bronchitis and pneumonia are frequent complications of the 
disease; and in addition there is often collapse of larger or smaller 
portions of lung-tissue from occlusion of some bronchus by the pseudo- 
membrane. In other instances, or frequently in conjunction with col- 
lapse of portions of the lungs, the violent respiratory efforts induce 



SYMPTOMS. 93 

either vesicular or even interstitial emph^^sema, especially of the ante- 
rior borders of the lungs. 

The morbid appearances found in cases where the croup has followed 
diphtheritic angina^ ^vill be fully described under the head of this latter 
disease. 

In the secondary croup of measles, the appearances are very similar 
to those observed in primary cases, while in that of scarlet fever the 
exudation differs in being less consistent and less uniformly spread over 
the diseased part. In the last-named malady, the membrane is thinner 
and less adherent, and, in some cases, puriform, soft, and of a grayish 
color. It is usually poor in fibrin, and prone to decomposition. The 
mucous membrane is generally discolored and softened. 

Symptoms. — In the majority of cases, the development of the symp- 
toms characteristic of croup, is preceded for a few diiys by the ordinary 
symptoms of catarrh and slight sore throat. The child is feverish 
and drowsy; there is cough, which may possess a slight croupy charac- 
ter at some period of the twenty-four hours, but more frequently seems 
like an ordinary catarrhal cough; coryza is very rarely present, but 
there is slight soreness behind the angles of the jaws, and the fauces 
are seen to be reddened, and probably small, thin patches of pseudo- 
membrane may be visible on the tonsils or fauces. This early stage 
lasts a variable time, usually from one to three or four days, and is 
more or less gradually succeeded by the symptoms indicative of laryn- 
geal obstruction. 

When, on the other hand, the disease begins in the larynx, the inva- 
sion is marked by hoarseness of the voice, and hoarse, croupal cough, 
which often continue for one, two, or three days, until the disease has 
made considerable progress, before the parents deem it necessary to 
send for a physician. In a case that came under the observation of one 
of ourselves, the child was playing about the room at a time when he 
had hoarse, whispering voice, and cough, and stridulous respiration. 
In another we were not called until the evening of the third day, 
though the child had had. stridulous cough and respiration for two 
nights; but, as he always seemed better in the morning, it was not 
thought necessary to send for a physician until after he had become 
violently ill. In a third case there was hoarseness of the voice and 
slight croupal cough during the afternoon of one day and the ensuing 
night, and the next morning fully developed croup, with fibrinous 
patches on each tonsil. These symptoms are not generally accompanied 
by fever at first. The appetite is usually unimpaired, the thirst 
scarcely augmented, and the child, though somewhat dull and languid, 
is disposed to be amused at times. In other and severer cases, on the 
contrary, the disease becomes aggravated much more rapidly, and may 
soon lead to a fatal termination. 

The change of the voice is the first symptom observed in the cases 
which begin in the larynx. It has always been described to us as hoarse, 
like that which is heard in an ordinary cold. As the disease progresses, 
the voice becomes more and more hoarse and difficult, until at length it 



94 PSEUDO-MEMBRANOUS LARYNGITIS. 

is reduced to a mere whisper. The degree of the hoarseness varies, how- 
ever, to a very great degree in the same case, the diversities depending 
probably upon the amount of the spasm of the larynx at the moment, 
and upon the state of the exudation. We have several times observed 
the voice to become much stronger and clearer after the operation of 
an emetic, in consequence, no doubt, of its relaxing effect upon the 
glottis. The cough is peculiar. At first slightly hoarse, it becomes, as 
the case goes on, very hoarse and hollow, and then short and smothered. 
It is variable in frequency, and is apt to occur in paroxysms, which are 
often very troublesome from their frequent recurrence. Towards the 
termination of the disease in fatal cases, or whenever the case is very 
severe, it is altogether different in character from what it was at the 
beginning, becoming short, instantaneous, and smothered, so that it 
might very well be called whispering. As the disease progresses, it is 
accompanied by stridulous respiration, in which a hoarse, rough, hiss- 
ing, or crowing sound is produced by the rush of the air through the 
constricted larynx. This sound is usually heard at first only during 
forced inspirations, and is therefore noticed first during the long inspi- 
ration which precedes coughing. Next it is heard during the violent 
respiratory movements which accompany the act of crying; and as the 
larynx becomes more and more clogged with the exudation, it occurs 
during both inspiration and expiration, in every act of respiration, and 
is so loud as to be heard over the whole room, or even in adjoining 
rooms. 

The resjpiration is natural in the early part of the attack, but as the 
voice and cough assume their characteristic features, and the stridulous 
sound is established, it becomes more frequent, rising to 28, 32, 40, and 
48 in the minute. At first easy and natural, it becomes,' during the 
height of the symptoms, and especially in fatal cases, the most fright- 
ful dyspnoea we have seen in any disease. Every movement of inspi- 
ration requires the whole force of the inspiratory muscles to lift the 
walls of the chest, and enable the air to find its way through the narrow 
and obstructed glottis ; each expiration, instead of being short and easy, 
as in health, and in nearly all other diseased conditions, requires a slow 
and laborious contraction of the expiratory muscles to expel from the 
lungs the air which they contain, and which hisses through the larynx 
with a sound nearly as loud as that produced during inspiration. The 
dyspnoea just described is for the most part constant, but exhibits 
paroxysmal aggravations from time to time. 

When a paroxysm of dyspnoea occurs, the expression of the child is 
that of the most terrible anxiety, or of the wildest terror. In some 
instances, the face becomes deeply red, then blue, livid, and finally pale 
and white, and for a moment life may seem extinct. In other cases, 
in which the dyspnoea is constant, the face is of a duskj'-red color, the 
expression anxious and haggard, and the child either lies on its side 
with the head thrown far backwards in a state of somnolence, or con- 
stantly changes its position from restlessness without noticing anything 
around it. 



SYMPTOMS. 95 

Jacobi (Amer. Jour, of Obstet., May, 1868, pp. 13-65) lays particular 
stress npou the fact that in membranous croup the dyspnoea exists both 
in inspiration and expiration, whereas in spasmodic catarrhal croup it 
is chiefly present in inspiration, and is due, he thinks, to paralysis of 
the crico-arytenoid muscles from oedema and infiltration, so that the 
vocal cords are brought into contact during inspiration. 

There is one further peculiarit}' about the dyspnoea in membranous 
croup to which we would direct especial notice, since we regard it as 
of the utmost importance. This consists in the occurrence, in certain 
cases, of a deep sulcus around the base of the chest, and of recession of 
the lower part of the sternum and the epigastrium during the act of 
inspiration. 

These phenomena are, perhaps, partly due to the violent action of 
the diaphragm, but undoubtedly their chief cause is the atmospheric 
pressure, which acts here, as it has been clearly shown by Jenner to 
act also in rickets to produce the deformities of the thorax character- 
istic of that disease. The normal relation which exists between the 
firmness and resistance of the thoracic walls, the power and rapidity 
of contraction of the diaphragm, the elasticity of the lungs, and the 
size of the orifice of the larynx, is here disturbed by the greater or 
less degree of occlusion of the larynx by membranous exudation. The 
calibre of the larynx being thus diminished, so that air enters the lungs 
but slowly, and the diaphragm contracting violently, there will neces- 
sarily be recession of the softer parts of the chest-walls at each inspi- 
ration. 

The persistence of these phenomena during inspiration for even a 
short time is, we believe, in the highest degree characteristic of the 
presence of false membranes in the larynx; and when, despite the use 
of emetics, this form of respiration continues, it constitutes one of the 
strongest indications for the performance of tracheotomy. 

There is no expectoration early in the disease, or it consists of yel- 
lowish viscous mucus. At a later period there is usually expectora- 
tion of false membrane, sometimes in the form of a complete tube, or, 
much more frequently, of small, irregular fragments, mixed with mu- 
cus, or with the matters ejected from the stomach by vomiting. To 
detect the membrane, the substances expectorated or vomited ought 
to be placed in water, when the former detaches itself from the mucus 
and other matters, and is easily recognized. It is not voided in all 
cases in which it is known to be present in the larynx. 

Thus of the 35 cases observed by ourselves, it was expelled by vom- 
iting or coughing in 12; in 21 none was rejected, though its presence 
in each case was proved by the character of the symptoms and by its 
existence in the fauces, by autopsy, or by the operation of tracheot- 
omy; in one there was expectoration of masses of viscid, yellowish 
fibrin, though none of membrane; and in one there was no positive 
evidence of its existence. M. Yalleix {Guide du Med, Prat., t. i, p. 330) 
states that of 51 cases, in which the symptoms were very carefully ob- 
served, no traces of the exudation could be discovered either in the 



96 PSEUDO-MEMBRANOUS LARYNGITIS. 

expectoration or in the matters rejected by vomiting in 26, though its 
existence was proved by post-mortem examination. 

Auscultation. — In the severe cases of true <;roup that have come 
under our notice, auscultation has been of little or no aid. In fact, 
the chest-sounds have been, in most cases, so completely masked by 
the loud shrillness of the laryngeal stridor, that we have been unable 
to judge with any satisfaction to ourselves of the condition of the 
lungs. It has been impossible to determine whether the inability to 
detect natural respiratory murmur depended on the small volume of 
air that found its way through the obstructed larynx, or on the fact 
that all sound was masked by the stridor. This is particularly unfor- 
tunate, since, w^ere it not for this circumstance, we might be able to 
judge by auscultation of the extent to which the bronchia have been 
invaded by the false membrane, — a matter verj^ important to deter- 
mine when the question of tracheotomy comes to be mooted in any 
case. 

In cases in w^hich the laryngeal obstruction is not very great, and 
the stridulous sound consequently less loud, we may auscalt the chest 
to some profit. The vesicular murmur is then either natural, or altered 
according to the state of the lung. 

But, though such has been our own experience in regard to ausculta- 
tion in croup, MM. Barth and Eoger {Trait. Prat, d' Auscultation, 2erae 
ed., p. 255 and 261) describe, as a sign of croup with floating false mem- 
brane, a kind of vibrating murmur, or tremblotement , as though a mov- 
able membranous veil were agitated by the respired air, and which can 
be heard when the stethoscope is applied over the larynx or trachea. 
If this sound be heard only in the larynx, and not in the trachea and 
bronchia, it indicates the plastic exudation to be of small extent, and 
likely to be rejected by expectoration, and the prognosis is favorable. 
In the other case, on the contrary, it shows the disease to be of consid- 
erable extent, and the prognosis becomes much more serious. 

This question will be found referred to more fully in our remarks on 
the indications for the operation of tracheotomy. 

There is a slight febrile movement at the onset, or a day or two after 
the appearance of the earliest symptoms. When the disease is fully 
established, the fever becomes violent. The pulse rises to 130, 140, 
160, or even higher; it is generally regular and strong at first, but as 
the case progresses, becomes small, feeble, and very rapid. In one of 
the paroxysms that we witnessed, it became so rapid that it could not 
be counted, and at last ceased to beat at either wrist for a few instants. 
The heat and drj^ness of the skin are very moderate at first, but in- 
crease as the disease reaches its maximum, to diminish afterwards 
gradually, and in fatal cases, to be replaced by coldness, with copious 
clammy perspirations. The strength is not diminished at first, but as 
the disease progresses, becomes more or less so in proportion to the 
violence and duration of the case. The digestive organs are but little 
disturbed by the influence of the disease, with the exception of dimi- 
nution or loss of appetite, and moderate thirst, during the violent 



MODE OF RECOVERY — DURATION — DIAGNOSIS. 97 

period. Spontaneous vomiting or diarrhoea are rare, though both some- 
times occur. The tongue is moist, and generally covered with yellow- 
ish-white fur. Pain in front of the larynx has been noticed by several 
authors. We have ourselves observed it in but one case. 

Tumefaction of the submaxillary glands, which is a frequent symp- 
tom of pseudo-membranous angina, ought always to be sought for, and 
when present lends additional support to the diagnosis. 

The mode of recovery in favorable cases is different in different in- 
stances. In some it is sudden, taking place rapidly and steadily after 
the expectoration of a tubular-shaped membrane. The rejection of the 
deposit in this form is, however, a rare event, and is not always fol- 
lowed by recovery. We have seen in this city three distinct tubules 
of false membrane, which were thrown from the larynx of the same 
child at intervals of two days each. The first was the largest, and 
came evidently from the whole length of the larynx and trachea; the 
second was somewhat shorter, and the third not more than half so long 
as the first. The child was greatly relieved for some hours on each oc- 
casion of the rejection of a tubule, but then became more oppressed as 
the exudation again collected. It sank from exhaustion after the third 
came away. 

As a general rule, the recovery is slow and gradual. After free vomit- 
ing, after the expectoration of fragments of false membrane mixed with 
mucus, or, as happened to ourselves in two cases, after the expectora- 
tion of masses of tough yellowish fibrin, or, lastly, after the rejection 
of mucoid and frothy sputa only, the symptoms gradually ameliorate; 
the stridulous respiration slowly subsides, and at last disappears; 
the cough, which was short, hoarse, and smothered, becomes louder^ 
stronger, less hoarse, and what is still more favorable, loose ; the aphonia 
moderates, but very slowly; the fever disappears; appetite and gayety 
return; and after a variable length of time, the child enters into full 
convalescence. The hoarseness of voice very generally continues for 
several days after all the other symptoms have lost their dangerous char- 
acter, and sometimes lasts for weeks. In one case, the voice was still 
weak and hoarse on the tenth day, and in another during the seventh 
week. {See a paper on Croup, by J. F. Meigs, 3£D., Am. Jour. Med. Sci., 
April, 1847.) 

Duration. — Death has been known to occur on the first, second, and 
third days, but such cases are rare. The duration of the disease may be 
stated at from three to thirteen days, as its most common term. The 
cases seen by ourselves lasted from five to fourteen days. 

Diagnosis. — There can be no difficulty in recognizing the presence of 
pseudo-membranous laryngitis, when the development of the symptoms 
of laryngeal obstruction has been preceded for several days by angina, 
with or without membranous exudation, and hoarseness of voice and 
cough. For the relation which exists between such cases and diphthe- 
ritic croup, the reader is referred to the remarks at the beginning of 
this article on the nature of croup, and to the remarks made under the 
head of diagnosis in the article on diphtheria. 



98 PSEUDO-MEMBRANOUS LARYNGITIS. 

When, however, the disease begins in the laiynx, and especially when 
there is no exudation whatever in the fauces, the diagnosis becomes 
more embarrassing, since under these circumstances there are two 
other laryngeal affections with which true croup may be confounded, 
— to wit : false croup or spasmodic catarrhal laryngitis, and laryngis- 
mus stridulus. The mode of distinguishing between these different dis- 
orders has been carefully described in the remarks on diagnosis, under 
the head of the former disease. We wish in this place merely to call 
the attention of the reader, and particularly of the young practitioner, 
to the extreme importance of the differential diagnosis between the 
disease now under consideration, and false or spasmodic croup, since 
the former is one of the most dangerous and frightful disorders to which 
children are subject, demanding vigorous and active treatment from the 
start, at which period only is medical treatment likely to be successful; 
whilst the latter, though of a much more threatening aspect at the be- 
ginning, is in fact a mild and safe disease in comparison, and one rarely 
requiring other than ver}' simple treatment. 

In this connection we would urge again the extreme imjDortance of a 
careful examination of the throat in every case where there are even the 
most trifling croupy symptoms present, since if membranous exudation 
be present either on the pharynx or tonsils, there is great danger that 
the laryngeal symptoms are due to an extension of the false membrane. 

Prognosis. — Pseudo- membranous laryngitis is a very fatal disease. 
In its sporadic form it is decidedly less dangerous than when it occurs 
in the course of epidemic diphtheria, owing to an extension of the ex- 
udation from the fauces into the larynx; but it still ought, at all times 
and in all shapes, to arouse the utmost caution of the practitioner. 

MM. Hilliet and Barthez state that its common termination is in death. 
M. Yalleix says that " to speak in general terms, it is fatal when not 
treated energetically." M. Guersent (loc. cit., p. 365), after a careful 
consideration of the statements of various authors, says: "In fact, 
true croup is one of the most dangerous of all diseases; it is generally 
fatal." He adds that he has seen at least 100 cases of spasmodic croup, 
without a single death, while of 10 children attacked with true croup, 
it is scarcely possible to save two. 

We have ourselves seen upwards of 200 cases of spasmodic or false 
croup, all of which without exception recovered, while of 35 cases of 
true croup that we have seen 16 died. 

The danger is great in proportion as the child is j'ounger and more fee- 
ble, and in proportion to the rapiditj^ of the case and the degree of the 
dyspnoea. The most unfavorable symptoms are: loud stridulous sound 
beard both in the inspiration and expiration; laborious and prolonged 
expiration ; recession of the base of the thorax during inspiration; whis- 
pering voice or complete aphonia; congestion of the face and neck; 
somnolence; weak, rapid, and irregular pulse; cold extremities; and 
cold clammy perspirations. The favorable symptoms are: expectoration 
of false membranes; diminution of the stridulous respiration ; the change 



TREATMENT — BLOODLETTING. 99 

from whispering to hoarseness or to clearness of the voice; looseness 
of the cough ; moderation of the fever ; improvement of the temper and 
moral state; and amelioration of the general condition. 

The case should not, however, be abandoned as hopeless until life is 
actually extinct. An instance has been elsewhere put on record by one 
of us (see paper by Dr. J. F. Jleujs, loc. cit.) of the recovery- of a child after 
momentary' suspension of animation from asphyxia on two occasions, 
thougii those attacks were followed by a dreadful illness of two days. 

Treatment. — We are desirous, at the beginning of our remarks upon 
the treatment of this disease, to express the opinion, that none is likely 
to succeed, unless it be applied early in the case, and by this we mean., 
in the course of the first, or at the latest, second day. And not only 
should it be commenced earh^, but the most active remedies ought to be 
applied at this period, in their full force. The veiy moment there is 
good reason to suppose that a case will prove to be one of membranous 
croup, the most energetic means ought to be brought to bear upon it, 
and if this be done from the first, or even second day, we cannot but 
hope that a considerably larger proportion of recoveries may take place 
than has heretofore been thought possible. 

In the study of the treatment, it will be necessary to rely chiefly upon 
the works that have been published since the distinction between the 
two forms of croup has been correctly drawn, for it is impossible to 
place much dependence on the assertions of previous writers, inasmuch 
as their opinions in regard to the effects of treatment must have been 
formed from indiscriminate experience in two very opposite maladies. 
It is only necessary to recollect the enormous difference in the mor- 
tality of the two affections, as shown by our own experience and the 
statistics quoted from Guersent, to be convinced that the success of any 
plan of treatment in the one, is no fair argument for its probable suc- 
cess in the other. The most important objects to be held in view in 
the treatment, are the foUow^ing: to prevent, if this be at all possible, 
the formation of false membrane; after its production, to cause its dis- 
solution, or render it less adherent; to provoke its expectoration; to 
prevent its reproduction after it is once expelled; to subdue the inflam- 
matory diathesis which exists; to allay the painful symptoms; and in 
every way to support the system. 

Bloodletting. — Some authors still award to bloodletting a high place 
in importance amongst the medical means in our possession, and it 
was formerly regarded by many in this country as an indispensable 
agent in the cure. Moreover, there are not a few who believe that, 
when promptly and boldly resorted to, it will seldom fail in arresting 
the disease. 

The more careful and extended study which this question has received 
during the past few years, however, has led many observers to doubt the 
efficacy of venesection in arresting the course of this inflammation, or 
preventing the formation of membranous exudation. 

In those cases where croup supervenes in the course of epidemic 



100 PSEUDO-MEMBRANOUS LARYNGITIS. 

diphtheria, there can be no doubt that bloodletting is entirely contra- 
indicated ; and the same remark may be made of those sporadic cases 
of pseudo-membranous laryngitis, where the onset of the disease is slow, 
and its course gradual, and unattended by high febrile reaction. In- 
deed, the more wide experience we have ourselves had in the treatment 
of this disease during late years, has convinced us that bloodletting is, 
to say the least, unnecessary, excepting perhaps in cases where the dis- 
ease occurs suddenly in vigorous children, and is attended at an early 
period of the attack by violent febrile action and especially marked 
suffocative symptoms. Under such circumstances, and such only, it 
may be advisable to resort to a moderate general venesection, prin- 
cipally for the mechanical relief thus afforded to the acute and intense 
venous stasis caused by the obstructed respiration. 

For all the other indications, however, for which bleeding was for- 
merly recommended in croup, namely, for the reduction of the fever and 
inflammation, and for the arrest of the exudative process, we prefer 
resorting to the other remedies hereafter mentioned. 

Emetics. — Emetics are recommended by all writers, and are generally 
acknowledged to be amongst the most, if not the most, efficient of all 
the means employed. M. Valleix {op. cit.,t. i,p. 358) has demonstrated 
their importance more fully than any other writer. He states that of 
fifty-three cases of the disease, tartar emetic and ipecacuanha were 
chiefly relied on in thirty-one, of which fifteen were cured; whilst of 
the twenty-two others, in which they were parsimoniously given, but 
a single one recovered. He gives other facts in regard to these cases 
which are highly interesting and important. Thus, of the thirty-one 
cases treated with powerful emetics, false membrane was rejected dur- 
ing the efforts of vomiting in twenty-six ; and of these, fifteen, or nearly 
three-fifths, recovered. In the five others of the thirty-one, on the 
contrary, no membrane was expelled, and they all terminated fatally. 
Again, of the twenty-two cases in which emetics formed but a second- 
ary part of the treatment, two rejected false membrane, and of these 
one recovered; while of the twenty others in which no false membrane 
w^as expelled, not one escaped. 

Our own experience in regard to emetics has been as follows : They 
were administered frequently and in full doses in thirteen of the 
twenty-one cases which began with angina; in six they were employed 
to a moderate extent, and in two not at all. Of the thirteen cases in 
which they were freely administered, eleven recovered; but, as in one 
of these life was saved only by tracheotomy, the success cannot be at- 
tributed to the emetics. Of the eight cases in which the emetic plan 
was not pushed, all but one ended fatally. Ealse membrane was re- 
jected in eight out of the thirteen cases above referred to. In one of 
the eight cases the quantity rejected was very small, and this was the 
case in which the child was ultimatelj^ saved only by operation. 

Of thirteen cases in which the disease began in the larynx, emetics 
were energetically used, and frequently employed, in eight. Of the 



TREATMENT — EMETICS. 101 

eio-ht, five recovered. In four of the eio-ht cases, frao-ments of false 
meinbraiie were rejected, and in a fifth, a mass of viscid, yellowish 
fibrin (this case was marked as one of unquestionable membranous 
croup by patches of false membrane on the tonsils). Of these five, four 
recovered. In three of the eight, no false membrane was rejected, and 
of these two died. In five of the thirteen cases they were not freely 
used, being employed in two only as a secondary means; in one other 
only at the very termination of the attack, as we were not called to 
the case until the tenth day, the patient having been under homoeo- 
pathic treatment before ; and in the remaining two cases they were 
not employed at all. Tracheotomy was performed in four of these five 
cases, but in only one was a successful result obtained. 

It is indeed true that there were peculiarities about the age and the 
type of the disease in the above groups of cases which may modify to 
some extent the conclusions which seem inevitable; but the state- 
ments and facts above given are quite sufficient to show that emetics 
exert a most powerful and beneficial influence on the disease, and that 
they ought, therefore, to form a princij^al and essential part of the 
treatment. 

The emetics generall}' employed in Europe and this country are 
tartar emetic and ipecacuanha, which are given in the usual doses to 
produce full vomiting. We would, however, strongly discountenance 
the employment of tartar emetic as an emetic, under any circum- 
stances, in children; and, at least in the disease under consideration, 
we do not like ipecacuanha as an emetic so well as one which, so far 
as we know, was first recommended by the late Dr. Charles D. Meigs. 
We refer to the Alumen of the Pharmacopoeia. 

In an article published by him in the Medical Examiner (vol. i, p. 
414, 1838), he says he has been "accustomed to make use of an emetic, 
Avhich, so far as I can learn, is very little employed, but which, from 
the certainty and the speediness of its operation, ought to be more 
generally admitted into the list of available medicines for this par- 
ticular case at least. I have been familiar with its effects fT)r more 
than twenty years, and my confidence in them increases rather than 
diminishes by time." He adds, " I think that I have never given more 
than two doses without causing very full vomiting; but I have often 
given large quantities of antimonial wine and ipecacuanha, without 
succeeding in exciting the efl'orts of the stomach." 

The alum is given in powder, in the dose of a teaspoonful, mixed in 
honey or syrup, or in syrup of ipecacuanha, to be repeated every ten 
or fifteen minutes until it operates. It is not generall}^ necessary to 
give a second dose, as one operates in the majority of cases very soon 
after being taken. We have known it to fail to produce vomiting only 
in two instances, both of which were fatal cases. In one the disease 
had gone so far before we were called, that no remedy had any effect 
upon the stomach. In the other, it was administered several times 
with full success, but lost its effect at last, as had happened also in 



102 PSEUDO -MEMBRANOUS LARYNGITIS. 

regard to antimony and ipecacuanha. The reasons for whicli we pre- 
fer alum to antimon)^, or ipecacuanha alone, are the following: Anti- 
inon^y. when resorted to as frequently in the disease as we are of opin- 
ion that emetics ought to be, is too violent in its action ; it prostrates 
many children to a dangerous degree, and is, we fear, in some cases, 
itself one cause of death. It acts injuriously upon the gastro-intestinal 
mucous membrane when used in large quantities and for any consider- 
able length of time. Again, it is very apt to lose its effect, and to fail 
to produce sickness. Ipecacuanha is a much safer remed}^ than tartar 
emetic, but its operation is often too mild, and it not unfreqnentlj^ fails 
to produce anj^ effect after it has been used several times. The advan- 
tages of the alum are that it is certain and rapid in its action, and that 
it operates without producing exhaustion or prostration beyond that 
which always follows the mere act of vomiting. It does not tend like 
antimonj^, and in a less degree ipecacuanha, to produce adynamia of the 
nervous sj^stem; an effect which, in some constitutions or states of the 
constitution, or when it has been exhibited frequently, is often attended 
with injurious or even dangerous consequences. We have given alum 
in the dose above mentioned every four or five hours, for two and three 
days, without observing any bad effects to result from it. The alum 
was given in all the cases that we have seen, in which emetics were 
used, and was usually the onlj^ one employed when it was found to 
produce full vomiting. In one of the cases accompanied by violent 
angina, ipecacuanha was substituted because of its smaller bulk. We 
have already said that it failed to produce vomiting onh^ in two in- 
stances. It was the emetic employed in the nine cases in which frag- 
ments of false membrane were rejected, and in that in which the yellow 
viscid fibrin was expelled. Although it did not occasion the rejection 
of membrane in the other cases, it operated most speedily and effici- 
ently. 

Sulphate of copper has been highly recommended by several writers 
for its emetic operation, and, by some of the German physicians, as ex- 
erting a specific influence upon the disease in addition to its emetic 
effect. As an emetic, it may be given to a child two or three 3^ears 
old, in the dose of from half a grain to a grain every fifteen minutes, 
until it operates. To obtain its specific action it is continued after- 
wards in doses of a quarter of a grain every two hours. 

We have also employed, with very good results, sulphate of zinc dis- 
solved in syrup of ipecacuanha, in the proportion of 2 or 4 grains to 
the fluid ounce. Of this, a teaspoonful maj^ be given to a child two or 
three ^^ears old, and repeated every fifteen minutes until it operates. 
This combination appears, like that of alum and ipecacuanha, to pos- 
sess the double advantage of mild action without the production of any 
subsequent depression. 

In the third edition of this work we referred to the use of the yellow 
sulphate of mercury (Hydrargyri Sulphas Flava) as an emetic in croup, 
as recommended by I)r. Hubbard, of Maine. Our own experience with 



TREATMENT — EMETICS. 103 

this remedy has been limited, and not very decided. In the American 
Journal of Obsfefrics, for ISIny, 1870, Dr. Fordyce Barker, of New York, 
speaks in the highest terms of praise of its emetic effects in this dis- 
ease. He always commences the treatment by a dose of from three 
to five grains, according to the age of the child, which may be repeated 
if it do not act, which he states very rarelj^ occurs, in fifteen minutes. 
This he follows up with the use of veratrum viride, and states that the 
treatment has been successful in every case of true croup in M'hich he 
has employed it. Undoubtedly this high testimony in its behalf justi- 
fies a further trial of turpeth mineral in cronp, though we confess to a 
suspicion that not a few of the cases in whose incipient stage he has 
administered this drug so successfully would have proved to be in- 
stances of the spasmodic and not of the true membranous form. 

We conclude these protracted remarks upon emetics with the state- 
ment that from what we have read, and from personal experience, we 
are induced to regard them as the most important remedies we have 
to oppose to this fearful malady. The emetic, whatever it may be, 
ought to be given three or four times in the twenty-four hours, and in 
severe cases, once in every four or five hours. The exact periods and 
frequency of the administration must be determined by the stage and 
urgency of the symptoms, and by the constitution and present strength 
of the patient. 

Mercury. — This powerful drug was first employed freely in the treat- 
ment of membranous croup in America, and has subsequently been ex- 
tensively used by English and European physicians. Calomel is the 
preparation almost always preferred, and many authors still recom- 
mend the administration of this remedy, in larger or smaller doses, in 
the earliest stage of the attack. 

During late j^ears, our increased dislike of the administration of mer- 
cury to children in large and frequently repeated doses, and the con- 
stant observation that even its free use does not appear to arrest the 
course of true croup, or prevent the formation of membranous exuda- 
tion, have led us to abandon entirely its employment in this disease. 

At the same time we believe there has been found, in the free admin- 
istration of the alkalies, an agency far less injurious than mercury, and 
equally powerful, if not more so, in promoting the separation and dis- 
charge of the exudation, and preventing its reproduction. 

The internal remedies, then, upon which, after emetics, we rely most 
surely, are various alkaline salts, the use of which in large doses has 
been of late years highly recommended, both at home and abroad. 
Those which we are most in the habit of employing are the chlorate 
and citrate of potash, which should be given in full and frequently 
repeated doses, as, for example, two or three grains every two hours 
to a child of four years old. We are also in the habit of combining 
with the chlorate of potash, tincture of the chloride of iron, in doses of 
three to five drops, at the same age. 

Antispasmodics are undoubtedly useful in some cases, when there is 
much laryngeal spasm. 



104 PSEUDO-MEMBRANOUS LARYNGITIS. 

Opium is, however, the best remedy that can be employed for this 
condition, since it constitutes an important element in the treatment, 
by alleviating pain and restlessness, at the same time that it relieves 
the laryngismus, and thus diminishes the asphyctic symptoms. We 
would consequently recommend the use of some of the preparations of 
opium, as the tinct. opii deodorata, in such doses and at such intervals 
as will maintain a gentle opiate impression. In this, as in many other 
diseases of children, it is better not to prescribe the opium in combina- 
tion with the other remedies that may be administered, but to either 
give it separately, or, better still, to add it to the dose of the other 
medicines at the time of administration, so that the amount of the dose 
of opium and the frequency of its repetition may be modified constantly 
in accordance with the condition of the child. 

Revulsives often prove useful in allaying restlessness, and moderating 
the violence of the suffocative attacks. Sinapisms and mustard poul- 
tices, applied upon various parts of the cutaneous surface, and mustard 
foot-baths, are amongst the best. The warm bath is often highly bene- 
ficial in the same way. 

We do not think it desirable ever to employ blisters in this disease. 

Local Treatment. — In those cases, and, as we have seen, they con- 
stitute the large majority of all cases of true croup, where the exuda- 
tion appears in the fauces or on the tonsils before it involves the larynx, 
local applications to the throat are undoubtedly of importance. 

The objects of such applications are here, as in diphtheritic angina, 
to promote the separation of the false membrane, and to prevent its 
reproduction. To fulfil the first of these indications, manj- authorities 
recommend astringent and caustic applications, which cause the pseudo- 
membrane to contract and shrink, and thus tend to promote its separa- 
tion; while others direct the use of those agents which exert a solvent 
action upon the exudation. 

In the former class, the most advisable are, alum ; tannic acid ; solu- 
tions of nitrate of silver; the astringent salts of iron, especially the 
tincture of the chloride and the perchloride ; dilute mineral acids and 
carbolic acid. 

Of these applications, those which we prefer are a solution of nitrate 
of silver, in the proportion of 5 to 20 grains to f^j of distilled water; 
and tincture of the chloride of iron, in the proportion of f5ss. to f5ij, to 
the f^j of water. 

The second group comprises chiefly solutions of various salines, as 
the carbonate of potash, bicarbonate of soda, chlorate of potash; and 
lime-water. 

If any of the astringent or caustic solutions are employed, we would 
recommend their application only to the patches of exudation in the 
fauces, since we regard it as highly doubtful whether they actually pos- 
sess the power of preventing the formation of membranous exudation 
when applied to the surrounding mucous membrane. Still more should 
we doubt the efficacy or advantage of introducing such solutions, and 



SUMMARY OF TREATMENT. 105 

especially the more po\Yerfal ones, into the larynx; either by pressing 
a soft sponge saturated with the solution upon the chink of the glottis, 
or by passing the sponge directly into the cavity of the larynx, as 
recommended by Dr. Horace Green. (Observ. on the Path, of Croup, 
d'C, Xew York, 1852.) The practicability of this proceeding is un- 
doubted, and a certain number of cases are on record in which it seems 
to have been used with success ; but we have never resorted to the 
treatment ourselves. 

In cases occurring in older children, who can be induced to inhale 
the vapor from an atomizer, or to allow a hand-ball atomizer to be 
used, the various astringent and solvent solutions above mentioned can 
be applied most satisflxctorily in this manner; and, when this is prac- 
ticable, we would prefer the use of lime-water or one of the alkaline 
solutions. 

In order to obtain the advantage which undoubtedly follows the inha- 
lation merely of the watery vapor, we are in the habit of causing the 
child to inhale the vapor from slaking lime for a few minutes in every 
hour, by covering the patient's body with a thick cloth, and holding a 
vessel containing the slaking lime a short distance below his mouth 
under the covering. It is doubtful, however, whether any appreciable 
amount of lime is carried up by the vapor so as to give the additional 
advantage of its solvent action upon the exudation. 

The reader is referred for more detailed discussion of this question of 
local applications in the treatment of croup, to the remarks upon treat- 
ment in the article on diphtheria. 

Hygienic Treatment. — The child ought to be warmly clothed, and 
confined to bed. The temperature of the room should be kept equable, 
and about 70° F. ; the air should also be frequently changed, so as to 
preserve it constantly pure and fresh. 

Owing to the loss of appetite and the pain caused by deglutition, it 
is often very difficult to induce the little patients to take food, so that 
this important element in the management of the case requires the 
utmost tact and attention. During the early part of the attack, the 
food should consist of light animal broths, beef tea, and preparations 
of milk. Later in the case, when the violence of the febrile action sub- 
sides, or if any symptoms of exhaustion and prostration appear, a small 
amount of wine and water, of wine whey, or of weak milk punch, should 
be given. 

Ice, given in small pieces to be held in the mouth, should be used 
very freely, as it relieves the parching thirst and at the same time ap- 
pears to act favorably upon the inflamed mucous membrane. 

Summary of the Treatment. — The general plan of treating this dis- 
ease should, therefore, in our opinion, be somewhat as follows : The 
child should be confined strictly to bed. The food should be light, di- 
gestible, but nourishing, and, upon the earliest approach of exhaustion, 
a stimulus should be administered. In the early part of the attack, we 
should advise the use of revulsives, with mild counter-irritants ; topical 



106 PSEUDO-MEMBRANOUS LARYNGITIS. 

applications to the fauces if there is any membranous exudation visible, 
and the internal administration of citrate of potash, with ipecac and 
small doses of opium, or of chlorate of potash with tr. ferri chloridi. 
So soon as the symptoms positively indicate the presence of false mem- 
brane in the larynx, we should resort to emetics, as directed in our re- 
marks upon those remedies. And finally, after employing these means 
faithfull}^ but without securing the discharge of the false membrane, 
while, on the other hand, the symptoms of laryngeal obstruction 
steadily progress, and the respiration grows more and more difficult, 
we must consider the propriety of resorting to the operation of trache- 
otomy, a proceeding which, as will bo seen from the ensuing remarks, 
we approve of under the above circumstances. 

Tracheotomy. — The operation of tracheotomy would be apt to sug- 
gest itself to a medical man, on his witnessing the closing symptoms of 
croup, as the very means most likely to afford to the patient relief from 
the dreadful sufferings under which he labors, and as a possible rescue 
from impending death. It has accordingly been often resorted to in 
different parts of the world, at various stages of the disease, but with 
results that have led to very different conclusions. 

In England, for example, the operation was almost universally con- 
demned and abandoned about ten years ago; and in a former edition 
of this work, we presented the unfavorable opinions of the most emi- 
nent English authorities. 

It was a matter of very great surprise, at that time, that the results 
of the operation in the hands of English surgeons should differ so widely 
from those obtained by the French physicians in similar cases. And, 
as there was no good ground for believing that sufficient difference ex- 
isted between the croup of Paris and London, to explain the difference 
of success in the two cities, it is probable that the great disparity re- 
sulted, in part, from the operation being performed in France at an 
earlier stage of the disease, and in part also from the more careful after- 
treatment which the patients received. 

Within the past few j^ears, however, the operation has been more 
favorabl}' regarded by English surgeons, and the statistics publisiied 
show that the proportion of success now obtained does not fall far short 
of that claimed by French operators. 

Thus in a paper read before the Eoyal Med.-Chir. Soc, in 1857, by 
Dr. Fuller, it is stated that up to that time 22 cases of tracheotonn^ in 
croup had been recorded in England, and that life had been saved in 
8 of these, or in 1 out of every 2| cases. 

In the statistical report of English Hospitals from 185-i-59, it appears 
that the operation had been performed in 15 cases with 4 recoveries, or 
1 in every of cases. Still further, from the statistics published by in- 
dividual operators in England, since 1858, though it is not to be pre- 
sumed that we have met with all the cases recorded, it appears that 
tracheotom}- has been resorted to in 63 cases, with successful results in 
24, showing a success of 1 in 21. 

When it is borne in mind also, that in each of these instances the 



TRACHEOTOMY STATISTICS. 107 

operation was postponed to the last suffocative stage, and that without 
exception the operators believe that the proportion of success would 
have been increased by its somewhat earlier performance, it becomes 
evident that tracheotomy has acquired a fair position in England among 
the legitimate operations of surgery. 

It is thus advocated by Fergnsson in the last edition of his Practical 
Surgery : and Dr. West, in 1859, speaks of it in these terms : "In spite 
of the unfavorable issue of the few cases in which I have either directed 
or sanctioned the performance of tracheotomy in croup, I am so far from 
being opposed to the operation, that my chief anxiety is to make out 
the indications which may justify me in having more timely recourse 
to it in future." 

In Germany, also, the operation, if not generally practised, is re- 
garded as fully justifiable, and recommended and successfully per- 
formed by many of the most eminent authorities. 

The statistics of the results there obtained, borrowed from Fock^ and 
Yoss,3 show that of 50 cases operated on in the last stage, 24 terminated 
favorably, giving a success of 1 in 2J3, or 48 per cent. Steiner has also 
recently published {Jahrb. f. Kinder heilk., No. 1, 1868) the results of the 
operation in 52 cases (33 boys and 19 girls), which show a recovery of 
18. or .34.6 per cent, of those operated upon; and in an article upon 
diphtheria and tracheotomy by Giiterbock l^Arch. d. Heilkunde, 1867, 
No. 6) lOJ cases, operated on in Berlin, are reported, with 33 cures. 

It is, however, in France that the operation first obtained, and has 
since firmly held, the position of a proper and legitimate method of 
treatment under certain circumstances of the disease. M. Breton neau, 
of Tours, was the first who practised it with sufficient success in France 
to give it some vogue. Since that time, it has been recommended and 
performed by many different surgeons and physicians in that country, 
and particularly, as is well known, by M. Trousseau, who has been un- 
doubtedly the most ardent and persevering, as w^ell as the most expe- 
rienced advocate of the operation. In one of his later publications 
upon this subject {Arch. Gen. de 3Ied., Mars, 1855, p. 259), he thus boldly 
advocates it : " For my part, I am quite determined not to allow my- 
self to be discouraged, but to preach tracheotomy with the greater con- 
viction in proportion as its success increases, and did this proportion 
remain what it was ten years since, I should still proclaim the necessity 
of the operation, nor cease to say that it becomes a duty, a duty as im- 
perative as the ligature of the carotid artery after a wound of that 
vessel, though death follows the operation as often, certainlj^, as re- 
covery. 

M. Guersent (Diet, de Med., t. ix, p. 376) recommends the operation 
when the usual therapeutical methods have failed, " as the only means 
that offers a remaining chance.'' He adds (p. 377) that he is certain it 

1 Eeport on Tracheotomy. Brit, and Por. Med.-Chir. Kev., July, 1860, from 
Deutsche Klinik, 1860. 

2 New York Journal of Medicine, January, 1860. 



108 PSEUDO-MEMBRANOUS LARYNGITIS. 

does not add to the danger of the disease. MM. Eilliet and Barthez 
(Mai. des Enfanfs, 2eme ed., t. i, p. 337) say that "the utility of trache- 
otoni}' in the treatment of croup cannot at this day be denied ; numer- 
ous cases of children snatched from a certain and imminent death, reply 
victoriously to any doubts that may be raised as to the truth of this 
assertion." The authors of the Comp. de Med. Prat. (t. ii, p. 587) re- 
mark that of late years, " the successful operations have been numer- 
ous enough to dispel the unfortunate prejudices which tracheotomy has 
hitherto inspired." M. Yalleix (Guide du Med. Prat., t. i, p. 388) says 
that the number of recoveries are " now too numerous to allow any one 
to think of opposing the operation except by statistics." MM. Hardy 
and Behier (Trait, de Path. Int., 1850, t. ii, p. 496), in speaking of the 
contest in regard to the propriety of the operation, say, '^But the ques- 
tion seems now to be definitely settled ; the operation has succeeded in 
fact in a little more than one-fourth of the cases in which it has been 
performed, and, in presence of these results, it may be said to become 
the duty of the physician to have recourse to it whenever, notwith- 
standing an appropriate treatment, the general and local symptoms 
indicate the extension of the false membrane." 

M. Bouchut (Trait, des Mai. des Nouv.-nes, 2eme ed., p. 316) says, that 
when medical means have failed, and the disease has produced a " state 
tending towards asphyxia, in which an attack of suffocation might 
cause the death of the child, there should be no hesitation; a new route 
must be artificially oj^ened to the external air; tracheotomy must be 
performed." 

At the time most of the above expressions w^ere written, a compara- 
tively small number of operations had been placed upon record in 
France, but they were quite sufficiently^numerous to show conclusively 
that, if the operation were carefully performed, and the after-treatment 
skilfully conducted, from 25 to 33 per cent, of the cases would recover. 
This excellent result is to be in great part attributed to the improve- 
ments introduced by Trousseau, and subsequently by other operators, 
both in the mode of performing the operation, and in the after-treat- 
ment of the cases. 

Since the publication of the last edition of this work the operation 
has continued to be so frequently performed in France, that we cannot 
find space to quote the results obtained by individual operators. The 
aggregate of their reports, however, as collected by Eoger and See, 
Chaillou, Barthez, &c., yield a result of about one recovery in four in a 
series of over 500 cases. 

The proportion of recoveries has varied considerably in different years 
in accordance with the type of the epidemic; in some years, as 1858, 
falling as low as 1 in 6.9 (121 operations, and but 18 recoveries), while 
in other years it has risen even higher than 1 in 3. 

It is further to be remembered that these French statistics are chiefly 
derived from the reports of the Hopital desEnfants in Paris, and refer, 
therefore, to a poor class of patients, who have in many instances been 
subjected to improper and debilitating treatment before reaching the 



TRACHEOTOMY — STATISTICS. 



109 



hospital, and who are exposed to unfavorable hygienic conditions while 
in the institution. When these unfavorable circumstances are allowed 
their fall weight, it must be conceded that the operation of trache- 
otomy has achieved a considerable share of success in France, and has 
fully justified the eloquent and enthusiastic advocacy of Trousseau. 

In America, tracheotomy has been resorted to but rarely until within 
the past few years. The statistics which have been lately published, 
however, fully suffice to show that, in the hands of American physi- 
cians, it has been very nearly, if not altogether, as successful as it has 
abroad. Dr. H. H. Smith {Oper. Surg., 2d ed., vol. i, p. 473) gives the 
results of 26 operations performed in this country, of which 9 recov- 
ered. Dr. Gay {Boston Med. and Surg. Jour., Jan. 27, 1859, et al.) re- 
ports 13 operations, with 7 cures and 6 deaths; and other operators in 
Boston have performed the operation in all 15 times, with 7 cures and 
8 deaths. But by far the most extensive statistics have recently been 
published by Dr. A. Jacobi, of New York (Amer. Jour, of Obstet., May, 
1868, pp. 13 to 65), derived exclusively from the practice of physicians 
in that city. 

The following table shows the results obtained : 

operator. 

Jacobi, 

L. Voss, 

E. Krackowizer, 

W. Von Koth, . 

Total, 

In this city the operation has been as yet but seldom resorted to, 
and with but moderate success, owing to the fact that in nearly every 
instance it has been postponed until the child was almost moribund. 
The following table embraces certainly the great majority of the opera- 
tions that have been performed; for a knowledge of which we are to a 
great extent indebted to the courtesy of the operators, since but few of 
them have as yet been placed on record 



No. of cases. 


No 


of cures. 


Percentage of 

success. 


. 67 


. 


13 


19J 


. 43 


. 


10 


. 23J 


. 55 


. 


16 


29 


. 48 




11 


23 


. 213 




50 


23* 



Name of operator. 

Physick, . 

Goddard, . 

Page, 

J. Pancoast, 

E. J. Levis, . 

T. H. Bache, . 

A. Hewson, 

H, Lenox Hodge, 

J. H. Packard, 

T. G. Morton, . 



No. of cases 
2 
2 
1 
6 
11 
1 
1 
3 
2 
1 

30 



No. of cures. 



3 
1 


2 

1 



Total, . .30 . . . 7 or 23.3 per cent. 

Finally, to sum up the statistics given above, although even this 
aggregate does not include by any means all recorded cases, Jacobi 
states (loc. cit.), that out of 1024 operations of tracheotomy, performed 



110 PSEUDO-MEMBRANOUS LARYNGITIS. 

in various parts of the world, but principall}^ in Europe, 220 or 21.48 
per cent, recovered. 

It is evident, therefore, that wherever this operation has been prac- 
tised in true croup, a considerable proportion of cures has been effected; 
but in order to form a clear opinion as to the real merits of the opera- 
tion, it is necessary to have some idea as to the number of subjects 
that might have recovered without a resort to it. 

This is verj^ easily arrived at in this country, since we believe that 
it is never performed here except as a last resort, when the patient is 
manifestly in great danger of death, or absolutely moribund. 

In regard to the French operations, it is not so clear whether some 
of the patients, who recovered after the operation, might not have been 
so fortunate without it, particularly as M. Trousseau formerly recom- 
mended that it should be performed so soon as we can be certain that 
the larynx contains false membranes. But then it is generally under- 
stood that he was not called to many of the cases upon which he oper- 
ated until all other means had failed, and the child had fallen into an 
apparently hopeless condition. To elucidate this matter, we shall quote 
the statements made by M. Yalleix, one of the most accurate and im- 
partial of writers. M. Yalleix {loc. cit., p. 388-9} tells us that he col- 
lected together 54 cases of undeniable, well-marked true croup, treated 
without the operation, and ibund that 17 had been cured. Then, ex- 
amining what had occurred in regard to the operation, he found, as M. 
Bricheteau had done before, that nearly 1 in 3 had recovered, a success 
almost precisely the same as had taken place in the cases treated by 
medical means alone. "But," he goes on to remark, "there is a con- 
sideration of very great importance, one which gives an altogether, 
different value to tracheotomy, to wit, that in the immense majority of 
instances, the operation was performed under the most discouraging 
circumstances, and only when all other methods of treatment had 
proved useless, and the severity of the symptoms, and the near ap- 
proach of asphyxia, indicated impending death So that it fol- 
lows that tracheotomy should be regarded, in connection with croup, 
as a genuine medical victory, the honor of which belongs to M. Bre- 
tonneau.and all preconceived views should fall before the actual facts." 
We have here the evidence of a most competent witness^ living on the 
spot, to convince us that the operation is not resorted to in France, at 
least generally, early in the disease, but is performed only as a last re- 
source, when the chance for the patient from the efforts of nature, or 
from medical means, is almost null. How, then, can we resist the con- 
viction that tracheotomy does afford a sufficient probability of success, 
after other means have failed and death is fast approaching, to render 
a recourse to it at least justifiable, if not almost compulsory? 

The second point to be examined in discussing the propriety of the 
operation is, whether it be in itself dangerous. 

From the opinions expressed by authors upon this subject, it appears 
that the only serious danger attendant upon the operation is the occur- 
rence of hemorrhage. When performed for the removal of foreign 



TRACHEOTOMY — ESTIMATION OF ITS VALUE. Ill 

bodies from the air-passages, the patients almost always recover if the 
foreign body do but escape. M. Ollivier (Art. Larynx, Corps Etrangers, 
Diet, de Med.) saj's that the success of the operation is, so to .speak, cer- 
tain, when it is performed early. Liston disapproves of the operation 
in croup, but states that it is not attended with much danger. Skey 
regards it as an operation of some difficulty and danger, from the irreg- 
ularity in the disti'ibution of the vessels, and the existence of numerous 
veins which ma}^ bleed profusel3\ M. Boyer does not regard it as dan- 
gerous, and states that the only danger is from the occurrence of venous 
hemorrhage into the trachea, and not from the amount of blood lost. 
Chelius says that it is dangerous below^the cricoid cartilage from anas- 
tomosis of the thyroidean arteries, from the presence of venous plex- 
uses, and sometimes from a deep thyroidean artery. Velpeau speaks 
of the venous hemorrhage as alone dangerous. Trousseau states that 
he has performed it more than 200 times, and has met with but a single 
fatal accident in all of these. Dr. Pancoast, of this city, who has oper- 
ated in more than 6 cases of croup, and a number of times for the re- 
moval of foreign bodies in the air-passages, has never met w^ith any 
serious difficulty in the performance of the operation, nor with any 
accident which he could suppose niight have affected the life of the 
patient. Dr. H. H. Smith (jjp. ciY., p. 474), when commenting upon the 
great disparity of the mortality after tracheotomy, when performed 
for removal of foreign bodies, and when for the relief of croup, remarks 
that it is very evident that the dangers which ensue upon incising a 
healthy trachea are comparatively slight, and that the great mortality 
which has attended the operation when performed for the relief of 
croup, must be due to some other cause than the mere incision of the 
windpipe. 

If, then, it is the uniform testimony of those experienced in the mat- 
ter that the operation is in itself alone but slightly dangerous to life, 
so that its performance adds but little to the danger of the patient; if 
it affords immediate relief to the suffocation which threatens to be soon 
fatal, and at least gives additional time, during which the gravity of 
the disease may subside; if, further, as we think has been most conclu- 
sively shown by the statistics quoted, it has unquestionably saved the 
lives of a considerable number of those upon whom it has been per- 
formed, it is difficult to avoid the conclusion that it is our imperative 
duty to resort to the operation under certain circumstances. 

That some who have been operated upon might have recovered with- 
out it, is highly probable; but the uncertainty as to the absolute neces- 
sity of resorting to it in any individual case is not even so great, prob- 
ably, as that which exists in regard to many other surgical operations, 
and to many medical applications. 

Our own plan, then, is to try faithfully all medical means; and, being- 
satisfied of their powerlessness and of the certainty of a fatal issue to 
the case without the performance of tracheotomy, to inform the parents 
of the inability of mere medical means to afford relief, and to propose 
the operation to them, setting before them the great probability of its 



112 PSEUDO-MEMBRANOUS LARYNGITIS. 

not averting death, but still strongly pointing out the fact that it does 
not add to the danger of the case, but gives so much additional chance 
for life that about 1 in every 4 operated upon recovers. 

Should they throw the whole responsibility upon us, we should, 
without hesitation, advise the operation. Our grounds for so doing 
are very simple, and have been before indicated. The operation does 
assuredly frequently save life. It is not in itself attended with any 
great danger. It cannot increase the danger of the patient's position^ 
but certainly gives an additional chance of escape from the disease; 
and, lastly, it mitigates, in a remarkable manner, the sufferings of the 
patient. On several occasions^ indeed, we have been told by the pa- 
rents, after the death of their child, that they were very glad it had 
been performed, since, at all events, it had removed the frightful gasp- 
ings and strugglings for breath which had previously convulsed the 
whole frame of the poor little sufferer, and had rendered his last hours 
easy and tranquil. 

If we decide that tracheotomy is justifiable, it becomes all-important 
to determine the period of the disease at which we should have recourse 
to it. 

M. Trousseau formerly laid down the rule that it was to be performed 
so soon as it was certain that false membranes had formed in the lar- 
ynx. He fixed upon this as the proper moment, because he believed 
that death was^ under these circumstances, almost inevitable without 
the operation. 

This opinion is, however, readily proved to be untenable. "We have 
already learned from M. Valleix that of 54 perfectly well-marked cases 
collected by himself, treated medically (without the operation), 17, or 
about a third, recovered. If we add to this that, of 35 cases seen by 
ourselves 15 recovered without the operation, it' becomes very clear 
that the mere presence of the exudation in the larynx is not sufficient 
warrant for a resort to the operation. 

Accordingly, most authorities advise that we should wait until med- 
ical means have been fairly tried. Thus, MM. Killiet and Barthez 
{op. cit., t. i, p. 340), in discussing the period at which the operation 
ought to be performed, conclude that it should not be resorted to until 
the means that have succeeded in other cases have been fairly tried, 
and it has become evident that they must fail. They advise the prac- 
titioner not to wait, however, too long a time, but to operate even 
early should the patient suffer a paroxysm of suffocation so severe as 
to make it probable that another might prove fatal. So, too, Mr. James 
Spence, in a valuable paper on tracheotomy (Edin. Med. Jour., Feb., 
1860), states, as the result of his large experience, "that if, in a case 
of croup, all measures have been activelj^ tried, if the hard^ ringing 
cough has become suppressed, and the respiration is evidently imper- 
fect, as shown by the contracted and depressed appearance of the car- 
tilages of the ribs, and the occasional severe paroxysms of dyspnoea, 
the operation is fuUy^warranted. When the paroxysms become more 
and more frequent, and when the dyspnoea is rather persistent than 



TRACHEOTOMY PERIOD FOR OPERATING. 113 

paroxysmal, with tnrgid or pale lividity, the operation is the little suf- 
ferer's only chance for life." 

The same course is, we believe, universally pursued in this country^ 
and. as the reader will recollect, corresponds precisely with the advice 
o'iven in our remarks on the medical treatment of true croup. 

The prime indication for the performance of the operation is, then, 
the degree of laryngeal obstruction as shown by the characters of the 
respiration, the cry, and cough. 

It should, however, be carefully borne in mind that great dyspnoea, 
or even asphyxia, when intermitting, do not so imperatively claim op- 
erative interference, since cases where the dyspnoea is of this character 
may recover without the operation. 

When, however, despite the use of all medical means, and especially 
the repeated administration of emetics, the dyspnoea grows steadily 
and progressively greater; when there is marked hissing laryngeal 
stridor, and, at each inspiratory effort, recession of the base of the 
thorax; when, in addition, the voice is whispering or suppressed, and 
the cough short, smothered, and muffled, the operation should, we 
think, be unhesitatingly performed. 

In thus defining the conditions under which tracheotomy is called 
for in croup, it is clear that we are not to be influenced at all by the 
mere period of the disease as measured by time, but that, whenever 
the above symptoms are present, the operation is indicated. 

There can be no doubt, however, of the far greater success of the op- 
eration when performed in the earty period of the attack, before the 
patient's strength is materiallj^ impaired ; and it is, therefore, highly 
desirable that the indications which render its performance necessary 
should be appreciated so soon as they appear. 

A still further argument in favor of the timely performance of the 
operation is adduced by Dr. George Johnson {British Med. Jour., Jan. 
15, 1870), who dwells upon its value at an early stage, when the indi- 
cations are present, on account of the danger of oedema of the lung 
from venous congestion, and of the coagulation of the blood in the pul- 
monary artery. 

Trousseau, also, in his last publication upon this subject (Clin. Med., 
2d ed., t. i, p. 450), speaks as follows: " I wrote in 1834, and repeated 
in 1851: so long as tracheotomy was not a trusty weapon in my 
hands, I said, we should operate as late as possible; but now that I 
can number many successes, I say, we should operate as early as pos- 
sible. In removing from this assertion whatever may seem too absolute, 
I still affirm it, by saying, that the chances of the success of the operation 
are so much the greater in proportion as it has been the earlier perfor7ned.'' 

Notwithstanding this, however, should we be called to a case where 
the last stage of asphyxia has been reached, it is still not too late to 
perform the operation. Thus, in one of the cases that occurred in our 
own practice and which ended favorably, this condition was fully devel- 
oped, and the bluish skin, drowsiness, and insensibility to pain, showed 
that the patient had already sunk into very advanced asphyxia. 



lU 



PSEUDO -MEMBRANOUS LARYNGITIS. 



Perhaps we cannot do better in closing our remarks upon this point 
than to quote the concise and forcible axiom laid down by Archam- 
bault : " We should never operate too late ; it is never too late to oper- 
ate, so long as death is not actually present." 

There are, however, certain conditions which have been thought by 
many authorities to contraindicate the performance of the operation, 
even under the circumstances above described. The first of these is 
the very early age of the patient, and it has been advised to refuse the 
operation in all cases occurring under the age of two years. It is un- 
questionably true, as might be expected, that age exercises a most 
powerful influence upon the prognosis after the operation, owing partly 
to the difficulty in performing it on account of the narrowness of the 
trachea and the shortness of the neck, but chiefly to the deficiency of 
vital power, and to the difficulty of nourishing the infant afterwards. 
Notwithstanding these influences which render the prognosis so unfav- 
orable in tracheotomy' before the age of two years, there are so many 
successful cases on record that the most tender age can no longer be 
regarded as a positive contraindication. The following list embraces 
the names of the operators and the age of the infants in the cases 
which have been successful at a very early age: 



Baizeau, 


at 


10 months. 


Vigla, . . . 


at 


17 


nonths 


" 


a 


15 


(( 


Potain, 




18 


u 


" (in hands of his 






Moutard-Martin, 




18 


u 


colleague), 




15 




Trousseau, . 




13 


a 


Isambert, . 




16 




Barthez, 




13 


u 


Archambault, 




13 




" 




7 


a 


u 




18 




Maslieurat Lagemand, 




23 


u 


Eo^er, 




19 













In adults, on the other hand, tracheotomy in croup is less successful 
than in children, probably because, as Trousseau suggests, the form and 
size of the larynx allow the pseudo-membrane to extend deeply into 
the bronchia before producing the symptoms of croup. 

There is another condition w^hich, it is thought by many, ought to 
constitute an insuperable bar to the operation, and the possible exist- 
ence of which, in any case, is one of the most serious objections that 
has been brought against its performance. The condition to which we 
allude is the presence of pseudo-membranous exudation in the bronchia. 

The existence of this condition must greatly lessen the chances of a 
successful operation, but that it renders success impossible, as has been 
supposed, cannot be admitted. MM. Rilliet and Barthez (^op. cit., 2eme 
ed., t. i, p. 338) say: "It has been said that one contraindication was 
the presence of false membrane in the bronchia. But, besides the fact 
that the s^^mptoms denoting its presence are uncertain, we cannot see 
in this a positive objection to the operation. Recovery has been 
known to occur, in eifect, after the rejection of bronchial false mem- 
branes, and we were ourselves witnesses of a remarkable example of 
this kind. And is there any better mode of facilitating the escape of 
foreign bodies than by opening to them a passage below the larynx ? 



TRACHEOTOMY — CONTRAINDICATIONS. 115 

lender such circumstances, we must expect, to be sure, a greater mor- 
tality than under more favorable conditions. This opinion is, more- 
over, that of M. Breton neau." Numerous cases are indeed on record, 
and we have ourselves met with such, where, after the operation, large 
membranous casts of the trachea and bronchia, w^hich could certainly 
never have escaped through the larynx, have been discharged through 
the tracheal opening, and their escape followed by complete recovery. 

It appears evident, therefore, that if in such cases, when death is 
even more surely imminent than in those instances when the exuda- 
tion does not extend below the larynx, tracheotomy affords even a very 
slight additional chance of recovery, it should be performed despite the 
fact that the child will in all probability die. 

But apart from this consideration, it must be borne in mind that sta- 
tistics prove that the false membrane extends below the larynx in about 
one-third of all cases, and still further, that there are no means by which 
we can with certainty determine in any individual case whether such 
extension has taken place or not. 

It was at one time thought that auscultation might afford the desired 
information, but more careful observation has shown that it is not to be 
depended upon. As already said, in most cases the laryngeal stridor 
is so loud as to mask all chest-sounds, and, even when this does not 
happen, we have frequently observed that no definite and reliable in- 
formation is to be gained from physical examination. The following 
cases may be quoted, out of the number on record, besides several that 
we have ourselves seen, as proving this statement. MM. De La Berge 
and Monneret (Comp. de 3Ied. Prat., t. ii, p. 587) mention a case in 
which they could not believe that the bronchia contained false mem- 
branes, as the vesicular murmur was extremely pure and was heard 
everywhere; and yet, during the operation, a false membrane was 
drawn out, which represented the trachea and the division of the prin- 
cipal bronchia. The child died in 15 hours. 

The late Prof. William Pepper, of this city, reported 2 fatal cases 
(Summary of Trans. Coll. Fhys., vol. iii, No. iii, p. 106) in one of which 
" distinct vesicular murmur could be heard throughout the lungs, 
marked only occasionally by sibilant and sonorous rales," a few hours 
before tracheotomy was performed. The child died 20 hours after the 
operation, and the exudation was found to implicate the larynx, tra- 
chea, the large bronchia, and even some of the smaller ramifications. 
In the other case, the state of the respiration was carefully examined 
the day before death, and not the least respiratory murmur could be 
heard over any part of the chest, and yet in this instance, the exuda- 
tion was confined strictly to the larynx; not a vestige of false mem- 
brane was to be found either in the trachea or bronchia. 

In a case recently attended by us, where tracheotomy had been per- 
formed, so that all laryngeal stridor was absent, auscultation, eight 
hours before death, revealed quite strong respiratory murmur, much 
obscured by snoring bronchial rales. The antero-lateral parts of the 
chest were alone ausculted. Death occurred somewhat suddenly 



116 PSEUDO MEMBRANOUS LARYNGITIS. 

from the lodgment of a very large tubular membrane from the left 
bronchus in the trachea: and at the autopsy there was a tubular mem- 
brane found extending throughout the trachea, and through the right 
bronchus to its third divisions. The left lung was collapsed and con- 
gested ; the right one distended and emphysematous. 

Since, then, we can learn little or nothing from auscultation or any 
other means, as to the presence of false membrane in the bronchia, the 
question becomes one of exj^edienc}^, so far as this contraindication is 
concerned, whether to leave two-thirds of the patients, many of whom 
could certainly be saved by the operation, to perish without an effort 
to save them, because one-third must probably die; or to perform the 
operation, with very little prospect of success in one-third, for the sake 
of the chance of saving many of the remaining two-thirds who must 
otherwise perish. 

The presence of pneumonia is also universally recognized as greatly 
lessening the chances of recovery after tracheotomy. It must be borne 
in mind, in regard to this point, that pneumonia is frequently over- 
looked, and indeed that it frequently cannot be recognized on account 
of the loud tracheal rales which hide all auscultatory sounds; while, 
on the other hand, its presence may be simulated by the occurrence 
of collapse of some portion of the lung, owing to occlusion of the 
bronchus leading to it. Millard suggests that the degree of dyspnoea 
may be of service as indicating the presence or absence of pneumonic 
complication. Thus he has found that in croup not thus complicated, 
the rate of respiration is from 32 to 48, while when pneumonia is pres- 
ent, it rises above 50. It is probable, also, that by a careful study of 
the temperature, the occurrence of pneumonia may be suspected by a 
marked elevation of several degrees. Pneumonia of one lung is not, 
according to Guersent, a contraindication, nor is even double pneumonia 
regarded by some operators as absolutely interdicting the operation, 
though at the same time we are not aware of a single instance in which 
it has been successfully performed where this condition was unquestion- 
ably present. 

Another condition in which tracheotomy is thought by many to be 
contraindicated, is when membranous croup occurs as a secondary affec- 
tion, during the coui-se of some constitutional disease other than diph- 
theria, as, for instance, scarlatina, measles, or pertussis. Such cases 
were regarded even by Trousseau as absolutely unfit for operative 
treatment. Still, that this contraindication, although of the greatest 
weight, does not entirely forbid tracheotomj^, is shown by a case of 
croup following scarlatina, in which Dr. Yoss operated, and the child 
survived 31 days, the tracheal wound being nearly closed. Millard 
also, in his excellent essay on tracheotomy (1)6 la Traclieotomie dans 
le Cas de Croup, Paris, 1858), records 3 cases of croup secondary to 
measles, successfully treated by operation. He regards croup occur- 
ring in the course of pertussis as far less unfavorable, since the violent 
cough favors the expectoration of the false membranes. 

There remains, finally, one condition to be indicated in which the 



TRACHEOTOMY — CONTRAINDICATIONS. 117 

operation is, in the almost unanimous opinion of authorities upon this 
question, absolutely contraindicated. We refer to the cases of pro- 
found general diphtheritic infection, where the danger of the child de- 
pends upon tlie constitutional disease, even more than upon the laryn- 
geal obstruction, where the blood is gravely altered, and the well-known 
tendency exists to the formation of pseudo-membranes upon all abra- 
sions or wounds, so that in all probability the operation would merely 
serve to invite the extension of the exudation- 
Trousseau opposes the operation under such conditions, in the follow- 
ing words: " If the diphtheritic infection have profoundly attacked the 
constitution ; if the skin, and especially the nasal passages, are occupied 
b}' the specific inflammation : if a frequent pulse, delirium, and prostra- 
tion show the system to be deeply poisoned, and if the danger is rather 
from the general condition than from the local lesion of the larynx and 
trachea, the operation ought never to be attempted, for it is invariably fol- 
lowed by death." 

Even under this most unfavorable of all conditions, however, there 
are not wanting some operators of wide experience, who still recom- 
mend the operation : thus Jacobi {loc. cit.) asserts, that whenever the 
indication of suffocative dyspnoea, s.teadily increasing and not relieved 
by emetics, exists, he would operate despite any complications, general 
diphtheria, or anything else, and uses this powerful language : " Seeing 
a person suspended by the neck and being strangled, we should hardly 
investigate the propriety of cutting the rope from the point of view 
that the sufferer might be or is affected at the same time with tuber- 
culosis, cancer, or diabetes." 

After a careful review of the entire question, we believe that the facts 
upon record justify the following conclusions: that the condition of 
success which excels all others is the predominance of the characters 
of asphyxia; that when these are so marked that death is imminent, 
the operation is justifiable despite any complications which may coexist, 
save perhaps the presence of grave general diphtheritic infection; 
and finally that, when no such contraindication is present, and the 
dyspnoea is continuous and increasing despite all other treatment, the 
operation is positively indicated, and it becomes the duty of the practi- 
tioner to recommend its performance, and, if the decision be intrusted 
to him, to unhesitatingly assume the responsibility of operating. 

We have already indicated with sufficient clearness the influence 
which the age of the patient, the period of the disease, and the charac- 
ter of the epidemic exert upon the results of tracheotomy. But we 
would again allude to the marked manner in which the result is modi- 
fied by the character of the previous treatment, and to the fact that 
its success is very much interfered with by the earlier employment of 
any debilitating measures, such as were, until lately, but too frequently 
adopted. 

We have more than once been asked by the parents of children, upon 
whom tracheotomy was about to be performed, or who had actually 
undergone it, what influence would be exerted by the effects of the 



118 PSEUDO-MEMBRANOUS LARYNGITIS. 

operation, should it be successful, upon a subsequent attack of croup; 
and since, as has already been seen from the cases quoted by us from 
our own experience, second attacks of croup are not very rare, it is 
interesting to know, that so far the statistics which bear upon this 
question tend to show that a previous attack of croup cured by trache- 
otomy is a favorable condition for its performance in a subsequent at- 
tack. Thus of 5 cases, collected by Millard, in which the operation was 
performed for the second time, every one recovered. The second oper- 
ation was uniformly found much easier, on account of the cicatrix of 
the former incision serving as a guide, and also on account of the slight 
amount of the hemorrhage. 

Mode of Performing the Operation. — Tracheotomy being an oper- 
ation which all physicians, whether experienced or not in the use of 
surgical instruments, are liable to be called upon to perform at a mo- 
ment's notice, no apology is needed for the introduction here of the 
details of its performance. The following account is in great part 
borrowed from the pages of that most experienced tracheotomist. Trous- 
seau,^ and from a very complete and practical discussion of the opera- 
tion by F. Howard Marsh, Esq.^ 

The child should be carefully wrapped up, so as to avoid all exposure 
to cold; and if an anaesthetic is to be emploj^ed, should be allow^ed to 
sit or lie in any position he may choose during its administration, as 
the constrained position necessary during the operation tends to in- 
crease the difficulty of breathing. He should then be placed upon a 
table, furnished with a thin mattress, and a folded pillow or roll of cloth 
should be placed under the shoulders and back of the neck, so as to put 
the skin of the throat upon the stretch, and render the trachea promi- 
nent. If the operation is performed during the day, the table should 
be drawn close to the window, and the patient's face directed toward 
it, so that a full light may fall upon the throat; if, however, it be at 
night, and there is not sufficient gaslight, a special assistant must be 
intrusted with the duty of holding the candles or lamp. An assistant 
is also needed to stand behind the patient and hold the head securely; 
and another, whose duty shall be to draw aside the successive layers of 
tissue and the bloodvessels with a hook, and to sponge the wound from 
time to time. 

The instruments needed are a sharp-pointed, slightly curved bistoury ; 
a blunt-pointed bistoury; two flexible hooks; a dilator to stretch the 
incision in the trachea so as to favor the introduction of the canula, and 
made like a pair of curved dressing forceps, with a little spur projecting 
backward, so as to catch in the tissues aud prevent its displacement ; 
and finall}^ a canula. The size and form of this canula are matters of 
great importance; and of late j^ears several marked improvements have 
been effected in them. The calibre of the canula should, as first clearly 
directed by Trousseau, be as large as possible without interfering with 

1 Clin. Med., 2eme ed., torn. i,p. 414 et seq. 

2 St. Earth. Hosp. Eep., vol. iii, p. 331 et. seq. 



TRACHEOTOMY — MODE OF PERFORMING THE OPERATION. 119 

its easy introduction into tlie trachea, and its curve should be that of 
a quarter of a circle. 

In regard to this very important question of the size of the canula, 
we are indebted to Mr. Marsh {loc. cif.) for a series of observations, 
which appear to indicate that a tube somewhat smaller than that rec- 
ommended by Trousseau, Fuller, and others, may be equally efficient 
and yet less irritating. By a series of careful measurements of the rec- 
spective diameters of the trachea and cricoid cartilage, he established 
the fact that the latter diameter is almost invariably less than that of 
the trachea, to an extent varying from 4'oth to /q^^^ ^^ ^^ inch. If, 
therefore, as his measurements show, the diameters of the trachea are 
as follows: during the first two years of life, ^gths of an inch; in the 
third year, ^ths ; in the fourth and to the seventh, JJths ; in the eighth 
and ninth, ^-Jths; and in the tenth, ^§ths; it will be seen that a canula 
having a diameter of ^ths of an inch will answer for children between 
the ages of 1 and 4 years; one of ^^^hs for children between 5 and 8 
years; and one of igths for children between 9 and 12 years old. 

It may be added that after the 12th year the diameters of the cricoid 
cartilage and trachea increase so rapidly, that the canula now usually 
made for adults, with a diameter of i4.ths of an inch, is rather small for 
children between 11 and 16 years old. 

The length of the canula should be sufficient to cause it to reach from 
J to 1 inch below the inferior angle of the wound in the trachea. 

The canula must also be double, the outer tube having abroad collar 
in front, with holes through which the band which passes around the 
neck and secures the canula in position, may be passed and tied. It 
should also be furnished with a key, which plays easily in a notch on 
the upper part of the inner tube. This inner tube must so fit the larger 
one, as to be readily removed and replaced, being secured in position 
by the little key above mentioned. 

In some canulas a still further improvement is introduced, by having 
the outer tube and collar merely yoked together by means of two arches 
on the collar, which receive small outjutting bars at the sides of the 
npper extremity of the outer tube, so that this can shift its position 
according to any pressure it may receive. 

There is also a canula recommended by Fuller, called the "bivalve 
canula," the outer portion of which is not a tube, but consists of two 
narrow lateral blades, which are easily compressed by the finger and 
thumb into the form of a thin wedge, and expand again when the pres- 
sure is removed. This instrument supersedes the need of any dilator, 
and has the great advantage of being readily introduced. It is evident, 
however, that it must produce much more irritation while in position, 
than a tubular canula, and in addition, when the inner tube has been 
removed, as is frequently required, its reintroduction causes pain and 
irritation, from the constriction of the mucous membrane which has 
bulged inward between the blades of the outer portion. Mr. Marsh, 
therefore, advises that when there is any difficult}^ in introducing the 
canula at the time of the operation, a Fuller's tube should be used, but 



120 PSEUDO-MEMBRANOUS LARYNGITIS. 

that this should be exchanged on the second day for odc whose outer 
portion is tubular. 

Although it is almost the universal practice to introduce a canula at 
the time of operation, its use has been objected to by several good au- 
thorities, as apt to cause inflammation and ulceration of the trachea, 
and to favor the development of pulmonary complications; and several 
plans have been suggested for the separation of the edges of the 
tracheal wound. Thus Mr. Adams, of the London Hospital, recom- 
mends the introduction of a strong metallic wire speculum, such as are 
frequently used in operations on the eyes, and Dr. Pancoast, of this 
city, employs a pair of blunt leaden hooks. 

In addition to the instruments already enumerated, some operators, 
following the practice of the Dublin surgeons, use a hook or tenaculum 
to fix the trachea, while the incision is being made through its rings. 
This proceeding has certain advantages, especially when it is designed 
to excise a portion of the trachea, or in case of venous hemorrhage, as 
the trachea can be raised above the pool of effused blood and speedily 
opened, which will usually check the bleeding. It is also of service in 
young children, because the trachea is then so pliable and yielding, 
that, unless the hook be used, its anterior wall may be easily driven in 
front of the point of the scalpel, till it is nearly or quite in contact 
with the posterior, in which case the latter also may be wounded. 
Trousseau, Millard, and others, however, strongly object to this practice, 
believing it to be dangerous to so fix the trachea and oppose the move- 
ments connected with the performance of the function of respiration 
which is already so much impaired. Our own observation would goto 
show that, while the advantages to be gained from fixing the trachea 
are undoubted, especially in young children, the dangers have been 
somewhat exaggerated. 

It has been recommended by several high authorities — Lawrence, 
Carmichael, G. H. Porter, Brainard, Fergusson — to excise a small piece 
of the walls of the trachea. By some this has been adopted with the 
view of dispensing with the use of a canula, but it is claimed that, even 
when one is employed, this practice renders its introduction more easy; 
that the tube fits the oval opening thus made much more accurately 
than a mere slit, produces less pressure upon the edges, and conse- 
quently is not so apt to cause caries of the tracheal rings. It seems 
never to be followed by narrowing of the trachea after the canula has 
been removed, as might be apprehended. 

This practice is followed by Dr. Pancoast, of this city, who, in the 
case he describes, excised an elliptical piece about one-third of an inch 
long and two-tenths of an inch broad, from the front part of the third, 
fourth, and fifth rings of the trachea. As already said, he does not 
employ either a canula or dilator, but holds apart the edges of the 
Avound made in the soft parts over the trachea by means of a piece of 
thick leaden wire, bent so as to form hooks at either end. The wire 
is of such a length as to fit accurately around the neck when the 
hooked ends are placed within the edges of the incision, and thus 



TRACHEOTOMY — MODE OF PERFORMING THE OPERATION. 121 

keep np just sufficient traction in opposite directions to maintain the 
wound open. 

In regard to the operation itself, almost all who have had much ex- 
perience in it direct that it must be performed with great deliberation 
and care. 

The incision through the skin should be nrtade precisely in the me- 
dian line of the neck, and should extend from the cricoid cartilage to 
a little above the sternum. The slight white fibrous line which marks 
the interspace between the sterno-hyoid and sterno-thyroid muscles 
should then be followed as a guide for the next incision, and the mus- 
cular masses drawn aside by hooks. 

The trachea is now exposed with the isthmus of the thyroid gland, 
and, occasionally, large thyroidean veins lying upon it, and great care 
must be observed to avoid wounding these on account of the trouble- 
some hemorrhage which is apt to follow. A still further reason for 
this caution is the occasional existence of an anomalous distribution of 
arteries, by which a branch of considerable size, or even the innomi- 
nate artery itself, passes over the trachea directly in the course of the 
wound. An}' bloodvessels may be drawn aside by hooks, and the isth- 
mus of the thyroid gland may either be treated in the, same way, or, 
if it cannot be drawn away far enough to allow a sufficient incision of 
the trachea, may be ligated in two places and divided between (Brain- 
ard, of Chicago), although, when possible, this had better be avoided. 
The trachea, having been thus carefully exposed, should be punctured 
just below the cricoid cartilage, and the probe-pointed bistoury being 
introduced, and its edge guarded by the nail of the index finger of the 
left hand, the opening should be enlarged downwards to the extent of 
two or three tracheal rings. 

It usually occurs that there is some hemorrhage during these incis- 
ions; but if it be venous and moderate in amount, the opening of the 
trachea should not be deferred, as the re-establishment of respiration 
will usually speedily check it. 

So soon as the trachea is incised, the dilator should be instantly in- 
troduced with the blades closed; and so soon as in position these 
should be moderately opened. Air now enters readily, and there is a 
discharge of mucus, fragments of false membrane, and blood, through 
the opening. The canula should then be introduced upon the dilator 
as a guide, its entrance being evinced by the increased facility of res- 
piration, and the escape of mucus and blood through its calibre. A 
guard of india-rubber or a disk of waxed cloth should then be placed 
between the guard of the external tube and the skin, to prevent any 
irritation or chafing, and the canula may be fastened in position by a 
tape passed around the neck. 

Should blood bubble up by the side of the canula, as Geraldes ob- 
serves, the wound in the trachea has been made too large, so that the 
blood gains entrance during inspiration, and a larger canula should be 
at once substituted. 

It occasionally happens, as in a case related by Trousseau, that the 



122 PSEUDO-MEMBRANOUS LARYNGITIS. 

trachea is lined by a false membrane, which is partly detached and 
pressed forward by the end of the canala, so that it completely occludes 
the opening, and thus even increases the asphyxia. When this occurs, 
the canula should be withdrawn, and an attempt made to seize the 
false membrane with forceps and withdraw it. 

When the operation has been a laborious one, emphysema of the 
neck may be met with, sometimes extending to a considerable distance, 
and causing great disfigurement or even seriously complicating the 
course of the case. It results from a want of parallelism between the 
cutaneous and tracheal wounds, or from marked disproportion between 
the size of the tracheal wound and that of the canula, or, as occasion- 
all}" may happen, from the escape of the canula from the tracheal 
wound. It has also happened that the inflamed and thickened mucous 
membrane is stretched over and driven before the point of the scalpel^ 
and so escapes a sufficient division. 

It has not been customary to use anaesthetics in the performance of 
tracheotomy. Fock, however, advises the use of chloroform, and states 
that he has never, even in extreme dyspnoea, found any ill effects to 
result from its employment. At first the dyspnoea is increased by the 
inhalation, but anaesthesia is speedily established, and then the breath- 
ing becomes much calmer than before. Dr. Yoss, who has also em- 
ployed it, reports equally favorably of its effects; and Mr. Marsh, who 
has seen it administered in at least twenty cases, believes that, when 
carefully and slowly given, it is most beneficial. It must be remem- 
bered, however, that, owing to the asph3^xia, the sensibility of the 
child is usually much blunted, so that, even without anaesthesia, the 
operation has appeared to us to cause but little pain, and has been 
borne by the little patients with scarcely any struggling. 

After-Treatment. — Immediatelj' after the successful performance 
of the operation, and the satisfactory adjustment of the canula, an al- 
most incredible change occurs in all the symptoms of the patient. 
The wild restlessness of the little sufferer, with the agonized, appeal- 
ing glances at those surrounding the bedside, and the frantic clutching 
at the throat as though to tear it open to admit air, the lividity of 
the surface, the noisy, hissing stridor of the respiration, all vanish as 
though by magic. Ver^^ frequently the child falls into a placid sleep, 
the skin and lips regain their normal color, and the breathing becomes 
regular, full, and nearly as silent as in health. This calm is not, how- 
ever, to be of long duration; there are frightful dangers still to be 
undergone, from which nothing but the most assiduous care and skilful 
treatment can enable the patient to escape with life. 

It may, in fact, be asserted that the much greater proportion of suc- 
cess which has of late years attended this operation, is to be attributed 
chiefly to the more judicious after-treatment which patients receive. 
Indeed, Trousseau has most truly said, with regard to the importance 
of this portion of the management of the cases, that tracheotomy, badly 
performed, but well treated afterwards, will end favorably in a third 
of all cases; whereas, tracheotomy excellent!}^ executed, but badly 



AFTER-TREATMENT. 123 

treated afterwards, will almost invariably be followed by a fatal termi- 
nation. 

It might, consequently, have been added to the contraindications 
already enumerated, that, unless we can secure constant and skilful 
attendance upon the case after the performance of the operation, there 
can be but little hope of obtaining a favorable result. 

Wherever it is in any way possible, the constant presence, by day 
and night, of a physician or student of medicine, should be secured for 
four or five days after the operation. When this is utterly impos- 
sible, all of those engaged in nursing the case should be carefully in- 
structed how^ to act in the event of any emergency, so that the child 
shall never be without the presence of some one competent and read}^ 
to render the prompt assistance which is frequently necessary to avert 
instant death. The details of the attention necessary will be given a 
little further on. 

One of the first points to which careful attention must be paid, is to 
give to the air to be inspired through the canula as much as possible 
the temperature and degree of moisture that the air attains by its nor- 
mal passage through the mouth and nose. Various means have been 
recommended to secure this object ; thus, a piece of loose coarse sponge, 
wetted with tepid water, and enveloped in a piece of gauze, may be 
applied over the canula; or, as directed by Trousseau, " the neck of the 
child may be surrounded by a cravat of knitted w'ool, or a large piece 
of muslin or gauze, so that the patient expires into this thick tissue, 
and inspires the air impregnated by the warm watery vapor which the 
expiration has just furnished." 

This is the only means adopted by Trousseau ; but we may, in addi- 
tion, b}" the aid of a spirit-lamp, keep shallow dishes of water evapora- 
ting in the room, and at the same time employ a thermometer to regu- 
late the temperature of the chamber, which should be uniformly kept 
at from 70° to 72° F., though the air should be changed frequently, so 
that it may be pure and fresh. 

By careful attendance to this clear but long-neglected indication, we 
not only prevent the rapid drying of the mucus in the canula and tra- 
chea, but, as Trousseau asserts, avoid to a great extent the occurrence 
of pneumonia or bronchitis as sequelae of the operation. 

In regard to the treatment of the wound itself, we have already al- 
luded to the advantage of placing a piece of lint spread with cerate, or 
a caoutchouc ring, beneath the collar of the canula to prevent any irri- 
tation of the skin. No sutures should be introduced into the skin in- 
cision, as the efforts during coughing will soon tear them out. Trous- 
seau strongly advises that the edges of the wound should be cauterized 
daily for the first three or four days, with solid nitrate of silver, in 
order to prevent the formation of diphtheritic deposit. 

It very soon becomes necessary, despite every care to render the in- 
spired air moist, to cleanse the inner tube of the coating of viscid, partly 
dried mucus which collects on its interior, and to efi'ect this, the inner 
tube should be removed as frequently as is necessary. The frequency 



12-4: PSEUDO-MEMBRANOUS LARYNaiTIS. 

with which this withdrawal is required varies in different cases, but it 
may be stated as a general rule, that it should be performed from four 
to twelve times in twenty-four hours. 

When the tube is clear, the respiration is almost noiseless, and hence 
the supervention of noisy breathing is usually the indication of some 
obstruction in the inner tube, which should immediately be withdrawn 
and cleaned. 

The drying of the mucus in its interior maybe partially prevented 
by dropping, every half hour, a few minims of tepid water into the 
mouth of the canula, and by smearing the inner surface of the tube 
with pure glycerin, every two or three hours. Some years ago,^ Bar- 
thez recommended instillations of tepid solutions of chlorate of soda 
through the canula after tracheotomy, in the hope of effecting the soften- 
ing of the false membranes, and their more rapid and complete expul- 
sion. Although he was inclined to attribute a beneficial effect to the 
practice at the time, it appears to have since fallen into disfavor even 
with its originator. 

We have ourselves employed lime-water in several cases, and always 
with obvious relief. We were induced to use it from its well-known 
solvent action upon pseudo-membranous exudation, and have generally 
employed it by atomizing warm lime-water through the canula every 
few hours, or so often as the breathing becomes noisy and labored, de- 
spite the removal and cleaning of the inner tube, from the collection of 
viscid mucus or pseudo-membrane below the end of the canula. The 
atomization has been continued for a moment or two, and has usually 
excited cough, while at the same time it softened the viscid mucus and 
enabled the child to reject it through the tube. So great, indeed, is 
the relief at times thus afforded, that in one case the little patient asked 
frequently that the use of the atomizer should be repeated. In all prob- 
ability it does good, partly by its mechanical action in exciting cough, 
partly by the softening effect of the watery spray, but partlj^ also, we 
are inclined to believe, by the action of the lime upon the mucus and 
pseudo-membranes. We are also in the habit of directing that the child 
shall breathe, for a few minutes in every hour, the steam from slaking 
lime, though in all probability this does not contain an appreciable 
amount of the lime itself. 

It occasionally happens, however, that the breathing becomes noisy 
and obstructed and remains so even after the withdrawal Of the inner 
tube, and the use of the atomizer. The cause of the obstruction then 
probably consists in the presence near the end of the canula, either of 
a collection of dried mucus or of a piece of false membrane too large to 
escape through the canula. If, under these circumstances, an access of 
dj^spnoea should ensue, the strings securing the canula should be in- 
stantly cut and the outer tube withdrawn. If this be followed by the 
rejection of false membrane and a return of quiet respiration, the can- 
ula may be returned; but if there is reason to fear that the trachea 

1 Bull. Gen. de Ther., May 30, 1858. 



AFTER-TEEATMENT. 125 

contains false membranes too large to escape through the tube, it is 
better to allow it to remain out permanently. 

Millard (loc. cit.) recommends that the external tube should always 
be removed at the end of twenty-four hours after the operation, when 
the track of the wound is usually patulous, being lined by plastic lymph, 
and after waiting a few minutes for the rejection of false membranes 
and cauterizing the wound, be again introduced. 

In those cases which progress favorably, it soon becomes necessary 
to decide at what date the canula shall be finally removed. It is evi- 
dent that this should be accomplished so soon as possible, as the tube 
acts the part of a more or less irritating foreign body in the neigh- 
borhood of delicate and important structures, and yet it is only in rare 
cases that the patient can endure its removal before the sixth or seventh 
day. 

At the end of the fifth day, therefore, the experiment may be tried 
of plugging the mouth of the canula with a little roll of wool, to learn 
in what degree the larynx has become patulous. Should the child be 
unable to take a single respiration, the experiment may be deferred for 
several days, but should breathing be performed through the mouth for 
several minutes, the measure may be repeated daily, in order togradu- 
.ally accustom the larynx to a resumption of its function. 

About the seventh or eighth day the tube may be removed for an hour 
or two ; and, if its abstraction be well borne, it may be finally withdrawn 
the following day, and the wound closed by bringing its edges together 
with adhesive plaster. It is very necessary to observe the caution, that 
the canula must never be removed unless some one competent to replace 
it is at hand. It occasionally happens, however, that the larynx remains 
impervious for a much longer time, and cases are recorded in which it 
has been impossible to remove the canula for fifteen, twenty-five, forty- 
four (Trousseau), or even one hundred and twenty-six (Fock) days; or 
even for months or years. The causes which thus delay the period at 
which the tube can be removed, are summed up by Mr. Marsh (loc. cit.), 
as follows : 

1. Obstruction of the larynx by false membranes, which have been 
known to linger in its cavity for at least fourteen days after the operation. 

2. A chronic inflammation and thickening of the mucous membrane 
of the larynx, which may remain after the acute disease has passed off. 

3. A narrowing or complete obliteration of the passage of the larynx, 
by the growth of granulations above and around the canula. 

4. An impairment or complete loss of those functions of the muscles 
of the larynx which regulate the admission of air through the rima 
glottidis. 

5. Adhesions of the opposed surfaces of the vocal cords. 

After the removal of the tube, the wound heals, either by contract- 
ing from the circumference toward the centre, when air escapes until 
the very last day ; or the tracheal wound first closes, and the cicatriza- 
tion then advances externally. The average time occupied by this pro- 



126 PSEUDO-MEMBRANOUS LARYNGITIS. 

cess of cicatrization, is about one month, though it may be completed 
in two weeks or be protracted for two months. 

Among the results which have been known to follow the prolonged 
stay of the canula in the trachea, are necrosis of the tracheal cartilages, 
and ulceration about the wound, or of the trachea around the canula, 
which, in several cases, has been followed by fatal hemorrhage. Suppu- 
ration among the deeper structures of the neck, even extending into 
the anterior mediastinum, has been noticed in a few instances, when 
the deepseated tissues of the neck had been much disturbed. 

General Treatment. — Having carefully discussed the management 
of the canula and the treatment of the tracheal wound, it remains to 
say a few words in regard to the general treatment of the patient after 
the operation. 

The most essential point to be secured is, unquestionably, the proper 
alimentation of the child. It is, however, frequently very difficult to 
induce it to partake even of the most tempting food. We should en- 
deavor to persuade it to take, as before the operation, nourishing animal 
broths, beef tea, milk^ custard, chocolate, wine-whey, or weak miik- 
23unch. If, however, these are refused, and the child expresses a de- 
sire for any other digestible article of food — as the breast-meat of fowl, 
finely minced, or the soft portions of oysters, or eggs — the taste should, 
be gratified. Occasionally ice cream will be taken willingly, when 
other food is refused; or, when both wine-whey and milk-2)unch are re- 
jected, iced wine and water, or brandy and water will be relished. Un- 
fortunately, however, it not rarely happens that, owing partly to the 
soreness of the throat and partly, undoubtedly, to the pain caused by 
the canula during the movements of the trachea in deglutition, the 
little i^atient utterly refuses to swallow more than a mere sip of iced 
water. Under such circumstances, so serious a complication is absti- 
nence, that Trousseau recommends that it should be forced to take a 
little food. "Do not fear," he says, "to employ intimidation. In such 
cases I have often — assuming an apparent severity, the expression of 
w^iich I have exaggerated — forced the child to eat, and so have pre- 
pared the way for a recovery, which, without this, seemed to me im- 
possible." 

Even by this means, however, it may be impossible to secure the ad- 
ministration of a sufficient amount of nourishment, and we would then 
advise the use of nutritious enemata, consisting either of the yolk of 
one egg, beaten up in an ounce of milk, or of one ounce of beef tea, and 
given about every four hours. If they appear to irritate the rectum, 
and are not retained, one or two drops of laudanum may be added to 
each enema. 

In comparatively rare cases there exists, in addition to this unwill- 
ingness to eat, a positive difficulty in swallowing liquids. This results 
from the inaction of the vocal cords and epiglottis, which allow the 
fluid to pass through the glottis into the trachea and bronchia, causing 
violent cough and escaping through the artificial opening. The child 
is so alarmed by this that it sometimes refuses all nourishment, and 



ILLUSTRATIVE CASES. 127 

can only be supported by nutritions enemata. Under these circum- 
stances, Trousseau advises that all liquid aliment should be interdicted, 
and that the food of the child should consist of very thick soups, ver- 
micelli boiled in milk or broth, hard eggs, eggs very much cooked in 
milk, and rare-cooked meat, in rather large morsels. If the thirst be- 
comes ardent, he allows pure cold water, taking care to give it either 
some length of time after, or immediately before, the meals, in order 
to avoid vomiting. This difficulty in swallowing rarely begins until 
three or four days after the operation, and does not usually last beyond 
the tenth or twelfth day. Sometimes, as M. Archambault has sug- 
gested, the child is enabled to swallow with ease b}^ closing the canula 
with the finger at the moment of deglutition, but at other times this 
fails entirely. 

In many cases the difficulty in inducing the child to swallow, after 
the operation, is so great that all medication must be suspended, ex- 
cepting the administration of small doses of opium, by the mouth or 
by enema, w^hich we would advise to be continued. 

Whenever it is practicable to give remedies, however — without in- 
terfering w^th the ability and willingness to take food — it is very im- 
portant to bear in mind that despite the very great relief which the 
operation may have afforded, it has by no means put a stop to the dis- 
ease, but has simply afforded the system another chance to overcome 
and cast off the constitutional affection. 

Of course, the use of emetics must be suspended, and so if, on any 
theoretical ground, any depressing remedies have been employed^ they 
should be discontinued. But we should recommend under such cir- 
cumstances, that the use of the combination of chlorate of potash, 
tincture of chloride of iron, and sulphate of quinia, should be jDcr- 
sisted in. 

We subjoin the histories of two cases of true croup, w^hich have 
lately occurred in our practice, and which will serve to illustrate clin- 
ically the remarks that we have made upon this disease. 

In both cases tracheotomy was performed by Dr. H. Lenox Hodge, 
in one instance with complete success, but in the other with a fatal 
result. 

The first and successful case was under the care of Dr. E. Boiling, of 
Chestnut Hill, and was seen in consultation by Dr. J. F. Meigs, and, 
subsequently to the performance of the operation by Dr. Hodge, by 
Drs. Edward Bhoads and William Pepper. 

The second case was visited by both of us from the first; and was 
attended, after the performance of the operation by Dr. Hodge, with 
the most zealous and skilful care, by Drs. Wharton Sinkler and M. 
Longstreth. 

Angina with Membranous Exudation on Tonsils — Membranous Laryngitis : 
Tracheotomy at end of second day — Complete Recovery. 

Case 1. F. W., set. Ih years, a delicate child, who at the age of 4 
years had suffered from a severe attack of true croup, frojn which he 



128 PSEUDO-MEMBRANOUS LARYNGITIS. 

recovered without the operation. On December 23d, 1868, he was no- 
ticed to have the symptoms of an ordinary cold in the head, with 
slight sore throat, some d^^sphagia, and laryngeal cough ; he was vis- 
ited and prescribed for by Dr. R. Boiling. On December 24th the 
cough persisted, and there was slight coryza and redness of fauces, 
but without any membranous deposit or any croupy symptoms. 

He was ordered small doses of Kermes mineral, Dover's powder, and 
nitrate of potash, and counter-irritation to the throat. 

At 5 A.M., December 25th, the child, who had gone to sleep quietly, 
waked in a frightful paroxysm of dyspnoea, gasping, clutching at its 
throat, and with oppressed whispering voice. 

Emetics of alum were given, and produced free emesis, but without 
the rejection of any false membrane, nor was any yet visible in the 
fauces. The powders were continued. 

The dyspnoea persisted and grew steadily worse; the voice remained 
suppressed. Membranous exudation Avas noticed in the evening on 
the tonsils, and during the following night, the obstruction to respira- 
tion became so intense that, after consultation with Dr. Meigs, trache- 
otomy was performed by Dr. H. Lenox Hodge. The trachea was 
opened just below the isthmus of the thyroid gland. JS"o false mem- 
brane could be seen at the level of the opening, nor was any rejected. 

A few hours later it became necessary to remove the canula, cut an 
oval piece from the trachea, and replace the tube, during which pro- 
ceeding artificial respiration had to be maintained. 

The neck was surrounded by gauze. Nutritious enemata, with small 
doses of laudanum, were given every two or three hours. Cream and 
brandy were given by mouth, and the attempt was made to give quinia 
and iron, but the child absolutely refused to take it. The breathing 
became somewhat easier, but at 9 a.m., December 26th, it was 66, and 
the pulse 160. 

The internal tube was frequently removed and cleansed of very thick 
viscid mucus, which rapidly collected in it ; and the other treatment was 
continued. In the afternoon it became evident that the internal tube 
was entirely too small, and it was therefore abandoned and the external 
one alone retained. Warm lime-water was now atomized down the tube 
every two hours, and on the first occasion of its use was followed by 
the rejection of a large piece of thick, dark-gray, glue-like false mem- 
brane. This was followed by marked relief to the d^'spnoea. 

The child was kept gently under the influence of opium ; and was 
nourished by enemata of beef tea, f^j ; brandy, fjj ; tr. opii, gtt. iv, 
given every three hours; which were retained unless they provoked a 
fecal discharge, which happened two or three times. The urine was 
passed freely, and was not albuminous. 

The respirations were conducted solely through the tube, and once 
during sleep fell as low as 32. 

December 27. — Still refused to eat, and the bowel also became some- 
Avhat irritable, so that several of the enemata were rejected. The respi- 
rations varied from 35 to 48; the pulse from 132 to 140. The treatment 



ILLUSTRATIVE CASES. 129 

was continued; the atomization of lime-water througii the tube being 
repeated every three hours. Towards the close of each interval the 
face becanie flushed, and the child grew restless, throwing the arms 
about excitedly, at times leaping up in bed, and turning round so as to 
lean forward on the pillows and hwry his face in his hand, or else look- 
ing round with an appealing expression. The atomization was alwaj'S 
followed by cough, and the rejection of pieces of false membrane and 
thick puriform matter. Towards evening he began to swallow some 
food. 

December 2^. — The tissues of the neck had become so much infiltrated 
and swollen, that the canula was no longer long enough to reach from 
the cutaneous surface into the trachea; it was in this way pushed for- 
ward till it obstructed the tracheal opening and caused great dyspnoea. 
It was consequently removed, and the child, though much exhausted, 
sank into a gentle refreshing sleep, with quiet regular breathing. The 
tube was not replaced, the breathing being readily performed through 
the wound. There was still marked indisposition to take food, and for 
a few times he was forced to swallow by holding his nose and pouring 
beef tea down his throat; this was not, however, continued, as the effort 
exhausted him very much, owing to his most violent resistance. The 
discharge from the trachea through the wound was quite fluid, puru- 
lent, and very fetid. A solution of carbolic acid, gtt. x, in Oss. of tepid 
water, was atomized through the wound; and the atmosphere of the 
room was kept impregnated by atomizing a stronger solution about the 
chamber. 

Daring the day he swallowed more food; gr. I of opium was given 
twice ; his circulation and respiration improved. 

December 29. — Condition still improving. Eespirations 28, quite full 
and deep, without rales; pulse had fallen steadily from 114 to 84, and 
was more full and strong. The color of surface was better. Eespira- 
tion carried on partly through the mouth. 

December 30. — The child passed a very comfortable day. The respi- 
rations were about 24; the pulse 78 to 86, soft, full, and strong; the 
capillary circulation good. Food was taken much better, the child 
eating a croquette made soft with cream, the soft part of several oys- 
ters, a small piece of breast of partridge cut fine and rubbed ujd with 
butter and salt^ and drinking sherry wine and water, and rich choco- 
late. The discharge had lost to a great extent its offensive character. 
Took gr. ss. of opium at night, and slept five hours quietly. 

December 31. — The child's condition was better in every way. The 
wound was contracting, the edges of the tracheal opening white and 
clean, and granulations beginning to project over it. The cough was 
stronger and more laryngeal, and the voice stronger and clearer, though 
still whispering. A good deal of the discharge was now raised into 
the mouth and expectorated. The gauze with which the wound had 
been covered was changed for a piece of patent lint^ to encourage the 
larynx to gradually resume its functions. 

From this time the case steadily improved. The matter expecto- 

9 



130 PSEUDO-MEMBRANOUS LARYNaiTIS. 

rated grew more and more mucoid, thin, whitish, and scanty, and fin- 
ally expectoration ceased almost entirely. The general symptoms 
rapidly improved, though he remained weak and nervous for six 
weeks. The external wound was covered with patent lint, at first of 
one. then of several thicknesses, and he gradually regained the power 
of breathing through the larynx, and of speaking. The larynx seemed 
quite clear after January 2d, 1869, eight days after the operation. The 
wound granulated from the bottom outwards, and was entirely cica- 
trized by the end of six weeks; by which time he was about the house, 
and had returned to his studies to occupy his mind, as he was very 
fretful and nervous. 

November 1, 1869. — F. W. remains perfectly well, and is indeed en- 
joying more robust health than for several years before this attack of 
membranous crouj). 

Angina loith ^nemlraiious ^patches on tonsils; Membranous Laryngitis ; 
Tracheotomy on tenth day ; Death on thirteenth day {fifty-eight hours 
after operation). Autopsy. — False membrane extending from tracheal 
wound to third division of bronchi; right lung emphysematous ; left 
lung collapsed ; blood dark and fluid. 

Case 2. K. B., girl. set. 6 years and 1 month ; rather tall for her age. 
Her parents are healthy; but she herself had suffered much from spas- 
modic asthma during infancy and first dentition. Since then she has 
enjoyed good health. On the morning of Tuesday, October 5th, 1869, 
she appeared unwell with a little croupy cough, which passed off in the 
middle of the day, and she was allowed to play in the square for a 
couple of hours. On Friday, 8th, her cough was worse, but still she 
seemed so bright that she was allowed to play about the room; but in 
the afternoon she complained of sore throat, and Dr. J. F. Meigs was 
called and found small patches of exudation on the tonsils. 

R. — Potass. Chlorat., gi"- ij- 

Tr. Ferri Chloridi, gtt. v. 

Every third hour in a teaspoonful of syrup and water. 

During the night, violent dyspnoea, with noisy gasping breathing, 
came on, for which emetics were employed with some relief. 

On Saturday, 9th, there were patches of membranous exudation on 
the fauces and tonsils. The cervical lymphatics were only slightly 
enlarged. The breathing was difficult and stridulous; the voice feeble, 
small, usually whispering, but when raised by an effort was rather 
piping and shrill; the cough was short and smothered. There was no 
coryza. Treatment continued, and inhalations of the vapor from slak- 
ing lime ordered every hour. 

On Sunday, 10th. — The child was restless, Avith at times marked 
jactitation; face flushed, and expression anxious; respiration labored ; 
inspiration imperfect, with shrill stridor; expiration prolonged and 



ILLUSTRATIVE CASES. 131 

stridiiloiis. 1^0 expectoration. Membrane still visible in fauces. No 
albumen present in urine. Pulse frequent, skin hot and moist. Treat- 
ment continued, and cloths wrung out from hot water applied to the 
throat. 

Monday, 11th. — Condition about the same; the degree of dyspnoea 
varying from time to time with degree of spasm, but the breathing 
still continuously labored and stridulous. Treatment continued, and 
frictions with turpentine liniment directed to be made to the throat. 
Marked unwillingness to eat. 

Tuesday, 12th. — There was marked improvement in the child's con- 
dition. The breathing was easier and less stridulous; the cough less 
frequent and looser, with a few thick yellowish purulent sj)uta; the 
voice was raised with less difficulty, and was clearer and stronger. 
There was, however, the same faucial pain and obstinate indisposition 
to eat. The fauces Vere still red and swollen, and a small thin patch 
of exudation was visible on one of the tonsils. The treatment was con- 
tinued, and the child also took a little port wine and water and beef 
tea, and had nutritious enemata of egg given every four hours. 

Wednesday. ISth. — The condition of the fauces was better, the breath- 
ing easier, and the voice more clear. The skin was still heated, pulse 
frequent, and there was still indisposition to eat. 

During the ensuing night the breathing again became more oppressed 
and tighter, with some return of stridor. The voice also became sup- 
pressed and whispering. The circulation was somewhat obstructed, 
the face becoming flushed, and the lips rather dark. 

Thursday, 14:th. — These symptoms were aggravated, and in the even- 
ing there was marked jactitation and restlessness. The respirations 
were 40 in the minute, and stridulous, with prolonged expiration; and, 
during the inspiratory efi'ortj with violent action of the external respi- 
ratory muscles, elevation of the shoulders, and recession of the base of 
the chest and of the epigastrium. There was also complaint of pain at 
the epigastrium. The cough was infrequent, short, smothered, and 
muffled. The eyes were anxious, staring and prominent, with large 
pupils. The pulse was frequent, 140, and small. 

During the night there was a steady aggravation of all these symp- 
toms. The respirations rose to 46, and became extremely obstructed, 
the recession of the base of the chest and at the epigastrium being un- 
usually marked during inspiration. The voice was whispering and 
almost suppressed ; the expression strained, appealing, and anxious; the 
face deeply flushed and the lips livid. There was the same complaint 
of constant pain at the epigastrium. 

Friday l^th, at 7i A.M., respirations 36, pulse 136. Tracheotomy 
was performed by Dr. H. Lenox Hodge, the trachea being opened just 
below the isthmus of the thyroid gland, and a small oval piece excised 
from its walls. A good deal of venous hemorrhage occurred during the 
operation, but stopped immediately after the trachea was opened, and 
the tube adjusted. 

No anaesthetic was used, but the child made no resistance, and evi- 



132 PSEUDO-MEMBRANOUS LARYNGITIS. * 

dently was slightly benumbed from asphyxia. Soon after the operation 
the respirations grew more easy, a large piece of false membrane was 
thrown off through the opening, the flush disappeaaed from the face, 
and the features became composed and placid. 

Yery soon after the operation the respirations fell to 28, and through- 
out the day remained easy and regular. The pulse fell to about 120. 
The child slept well, but would eat but little, and still had enemata of 
beef tea, fgj, q. t. h., given it. The air of the room was kept pure, but 
warm and moist. The canula was covered with folds of gauze mois- 
tened with lime-water, and the wound was covered with a piece of 
greased linen, so as to protect it from the canula. The inner tube was 
removed every hour, cleaned, anointed with glycerin, and returned. 
Warm lime-water was atomized through the tube every three hours, 
and always produced strong coughing, with the expectoration of thick 
purulent matter, aud occasional!}^ of flakes of tough white false mem- 
brane. All medication was suspended, save the administration of gtt. 
ij, or iij, of Tr. Opii Deodorata sufficiently often to keep the child 
gently under its influence. During the ensuing night the internal 
tube was removed, owing to the difficulty in expelling the thick viscid 
mucus. 

Saturday^ IQth. — The respirations were 24; pulse 116. During the 
day the child took more beef tea and wine and water, but still had nu- 
tritious enemata given. There was great thirst, and she still complained 
of pain in swallowing. There was no coryza, and very slight, if any, 
enlargement of the cervical Ij^mphatics. 

Towards evening, breathing again grew obstructed, evidently from 
accumulation of mucus and pseudo-membrane below the end of the tube, 
which was consequently removed. Its removal was followed by the 
discharge of several large pieces of false membrane through the wound, 
the edges of which were well consolidated by lymph. The breathing 
quickly became noiseless, easy, and tranquil again. During the follow- 
ing night the child enjoj^ed some refreshing sleep, and took more nour- 
ishment. The atomization of lime-water through the tracheal opening 
was repeated about every two hours, and with such great relief that 
she several times asked for it herself by signs, as it each time provoked 
cough, and caused the expulsion of thick purulent matter, dried mucus, 
and shreds and flakes of false membrane. Urine was discharged freely, 
and contained no albumen. 

Sunday, 11th. — In the morning she appeared quite comfortable. The 
voice was still whispering, but the cough seemed looser, and she ex- 
pelled purulent matter more freely through the opening; no false mem- 
brane was discharged. The thirst was still great, but the child took 
beef tea more freely. The bowels have for several days been opened 
two or three times daily. Eespirations 20-25; quite full, without re- 
cession of the base of the chest. Pulse 130-136, of rather better volume. 
Hands fairly warm, though at times there was a little tendency to cool- 
ness. The wound was evidently contracting. Slight emphysema of 



ILLUSTRATIVE CASE — AUTOPSY. 133 

the base of the neck, which caused complaints of pain about the neck 
and shoulders. 

At 4 P.M. it was observed that the breathing was again growing ob- 
structed, and that there was recession of the base of the thorax during 
inspiration. Lime-water was freely atomized through the opening, but 
without causing any discharge of membrane. The difficulty of respira- 
tion increased until 5* p.m., when suddenly symptoms of asphyxia ap- 
peared. Prolonged efforts at artificial respiration were made^ and life 
was thus maintained for a short time, but no essential relief was afforded, 
and death soon followed, on the thirteenth day of the disease and fifty- 
eight hours after the operation. 

The chest was frequently ausculted throughout the course of the case. 
Before the operation it Avas impossible to isolate any respiratory mur- 
mur, owing to the loud, snoring, whistling, and cooing tracheal and 
bronchial rales. After the operation, and still more after the final re- 
moval of the canula, a faint respiratory murmur could be detected, 
mingled with the above rales. On the morning before death only was 
there an obscure flapping sound transmitted to the ear with the 
tracheal and bronchial rales, but even then it was indeterminate in 
character. 

During the efi'orts at artificial respiration, a long tubular false mem- 
brane was ejected. It had evidently been the immediate cause of death. 

Autopsy, twenty-four hours after death. Brain not examined. 

Thorax and Air-passages. — The wound in the neck looked well, with- 
out pseudo-membranous exudation. The larynx itself could not be ex- 
amined. A long false membrane, extending from the tracheal opening 
down through the right bronchus to the third or fourth division, lay 
loose in the trachea, having been detached from the mucous membrane. 
In the bronchia it was still slightly attached, but separated readily on 
traction. It was firm, very tough, and white, and, in the upper part 
of the trachea, at least one line thick. Below the bifurcation it was 
tubular for the rest of its course; and in its terminal portions grew 
softer and more yellowish. There was also, in the trachea, a large 
patch (IJ inches long by I inch wide) of false membrane, of dull white 
color, and tightly adherent. Upon raising it, numerous little delicate 
fibrous prolongations were seen attaching it to the mucous membrane. 
Beneath this patch the mucous membrane was deeply reddened, dry, 
excoriated-looking, and slightly roughened by minute elevations. There 
was no enlargement of the mucous follicles. The vascularity of the 
mucous membrane diminished in the lower part of the trachea, and 
was but slightlj^ marked in the secondary divisions of the bronchi. No 
ulceration was seen at any point. There was no pseudo-membrane in 
the left bronchus or any of its branches, and the mucous membrane 
here was less reddened than on the right side. In all probability the 
false membrane removed immediately after death had come from the 
left bronchus. The right lung was largely distended, the posterior 
border dark and congested, but the rest of the organ pale and emphy- 
sematous. The left lung was dark, purplish, non-crepitant, collapsed, 



134 DISEASES OF THE LUNGS AND PLEURA. 

and yielded on section an abundant flow of dark, airless, bloody serum. 
No pleurisy or pleural effusion. 

Heart. — The left ventricle was very firmly contracted and empty, and 
the tissue of its walls hard, tough, and florid red. The walls of the 
right ventricle were relaxed, and the cavity filled with fluid dark blood, 
without any clots. JSTo excess of pericardial effusion. 

The liver and kidneys were gorged with dark blood. 



CHAPTEE 11. 

DISEASES OF THE LUNGS AND PLEURA. 

GEXERAL REMARKS. 

It would be difficult, perhaps, to overestimate the importance to 
the medical practitioner of a thorough knowledge of the different 
diseases of the lungs and pleura, as they occur in children. The dis- 
eases of the respiratory organs — and much the most frequent of them 
are pneumonia and bronchitis — cause^ according to West, very nearly 
a third of all the deaths under five years of age in England; while 
not above one child in four dies under that age from diseases of 
the nervous system, and not above one in seven from those of the 
digestive system. In this country, it would seem, from the bills of 
mortality, that a larger proportion of children die of diseases of the 
digestive than of the respiratory system. But, while this is true, there 
can be no doubt that the diseases of the latter system are deserving of 
our utmost attention, since not only are they of constant occurrence 
and of fatal tendency, as idiopathic affections, but since, also, they fre- 
quently appear as complications in the course of other diseases, adding 
greatly thereby to their severity and danger. In measles, for instance, 
by far the most frequent cause of danger is the occurrence of some 
inflammation of the lungs or pleura. In scarlatina and typhoid fever, 
bron(;hitis and pneumonia are very common accidents, and recent re- 
searches have shown that in hooping-cough, and in all states of great 
debility and prostration, a certain change in the condition of the pul- 
monary^ tissue, to which the term collapse has been applied, is very apt 
to occur. 

The morbid condition of the lung last referred to, that of collapse, is 
one that has been well understood only within a few years past, and 
yet it is so important a one, in a practical point of view, as to excite a 
feeling of surprise that it had not been discovered before. 



ATELECTASIS PULMONUM. 135 

AETICLE I. 

ATELECTASIS PULMONUM, OR IMPERFECT EXPANSION OF THE LUNG. 

The title of atelectasis pnlmonum, from azeXriq^ imperfect, and ey.racnq^ 
expansion, was first employed by Dr. Edward Jorg, to designate a con- 
dition of the lungs observed by him in new-born children, a condition 
in which larger or smaller portions of those organs had never been 
penetrated by air. The respiration of the infant had, in such cases, 
been only imperfectly established at birth, and some parts of the pul- 
monary tissue had, consequently, never undergone expansion under 
the distending influence of the inspiratory act ; these undilated parts 
continued in the foetal state. 

In addition to this congenital form of imperfect expansion of the 
lung-tissue, this condition is met with at all ages of life, though with 
especial frequency in young children, as the consequence of a collapse 
of portions of the once-expanded lung, or, in other words, of their re- 
turn to the foetal or unexpanded state. To this latter form of imper- 
fect expansion, the terms post-natal atelectasis, collapse, and foetal con- 
dition have been given. Before the discovery of its real nature was 
made, it had often been described also under the well-known names of 
carnification and lobular pneumonia. We shall designate it by the title 
of collapse or post-natal atelectasis, while under that of congenital ate- 
lectasis pulmonum^ we shall describe the congenital variety of imper- 
fect expansion. 

CONGENITAL ATELECTASIS. 

Anatomical Appearances. — In congenital atelectasis the parts of the 
lung most frequently affected are the posterior portion and lower edge 
of the inferior lobes, the middle lobe of the right lung, and the languette 
and lower edge of the upper lobes. In some instances that we have 
examined, the greater part of the lower lobes of both lungs, while, in 
others, still larger portions of these organs have been found to present 
this condition. The imperfectly expanded portions of the lung are of 
a dark-red, or purplish color, and are diminished in size, so as to be 
depressed below the level of the healthy parts. They are solid to the 
touch, and yet they have not lost their cohesive properties, as they are 
neither friable, easily torn, nor readily penetrable by the finger; their 
cut surface is perfectly smooth; they do not crepitate under the finger, 
and np air-bubbles are seen in the fluid squeezed out by pressure; they 
sink when thrown into water. They, in fact, resemble exactly the foetal 
lung. The most convincing proof of the real nature of this condition is 
obtained by the inflation of the lung. When this is done, the depressed, 
hard, and dark-colored portions — unless the subject from whom the 
specimen has been taken may have lived long enough to have allowed 
the different tissues of the lung to become adherent — rise to their 
natural level, become elastic, soft, and crepitating, and change, under 



136 CONGENITAL ATELECTASIS. 

the influence of the entering air, from a dark and livid tint, to the rosy 
or pink color of healthy pulmonary tissue. In recent cases, this infla- 
tion is performed with great ease and with perfect success, while in 
other instances, in which the child has lived for some weeks or months, 
the distension is either eff'ected only by strong efforts, or in a very im- 
perfect manner, or it may fail entirely, owing to some permanent 
change having taken place in the tissues of the unexpanded portions. 
In a case that occurred to ourselves, the subject of which died at the 
age of fourteen months, of acute pleurisy of the right side, after having 
presented, at birth and throughout its short life, many of the symptoms 
of atelectasis, the inferior two-thirds of the lower lobe of the left lung 
exhibited in the greatest perfection all the atelectasial characteristics. 
The wliole of the unexpanded part was distended by means of inflation 
with a blowpipe, but only after repeated and powerful expiratory efforts; 
and Dr. E.Wallace, who made the examination, assured us that he was 
obliged to use a degree of force much greater than he ever employed 
to inflate healthy adult lung. 

In some cases, there are found small patches of vesicular emphysema 
associated with the areas of pulmonary collapse. If, in consequence of 
commencing post-mortem decomposition, there has been any develop- 
ment of gas in the tissue of the lungs, it is seen, by the aid of a lens, in 
the form of irregular air-bubbles scattered through the interstitial tissue, 
which are easily distinguished from the minute shining air-bubbles, 
crowded together in regular arrangement, which are seen in lungs which 
have been inflated. — Bouchut, Joi^r./. Kinderkrankheiten, 1863, 3-4, p. 263. 

In most cases, the foramen ovale and the ductus arteriosus are found 
to be still open, or the latter has but partially closed. 

The causes of congenital atelectasis have not been satisfactorily as- 
certained. The conditions that are probably the most frequent causes 
are : original debility of the infant, from any cause that has interfered 
with its i^roper development in utero, as feeble health on the part of 
the mother during pregnancy, or multiple pregnancy; and acquired 
debility, brought about by the fact of the infant's being exposed at 
birth to unfavorable hygienic influences, and particularly to those 
Avhich interfere with the proper performance of the respiratory act, as 
cold, a vitiated and close atmosphere, and the use of too heavj^ or tight 
clothing. A very hurried and rapid labor has been thought to cause, 
in some instances, this imperfect expansion of the lung-substance. In 
a case that occurred to one of us (see Am. Jour. Med. Sc, Jan., 1852, p. 
83), the only explanation of the condition, which seemed at all plausible, 
was that the placenta had been separated from the uterus at too early 
a period of the labor, in consequence of the violent and rapid character 
of the latter, so that the child was for a short time before birth cut off 
entirely from its connection with the mother, — a time sufficient so to 
lower its vital forces, as to bring on a condition resembling syncope, 
and to deprive it of the muscular strength necessary on entering the 
world, to produce a full expansion of the thoracic cavity, and so of 
course to effect a dilatation of all parts of the lungs. 



SYMPTOMS. 137 

In addition to this, congenital collapse of the lungs may result from 
the air-passages of the child becoming obstructed with mucus or fluid 
in consequence of the umbilical cord being ruptured during labor, and 
an inspiration thus becoming necessary, before the head is free from the 
liquor amnii or the secretions of the mother's passages. Finally the 
want of expansion has been in some cases found to be dependent on pres- 
sure upon the medulla oblongata, implicating the roots of the pneumogas- 
tric nerveS; resulting from inflammatory exudation or from effusion of 
blood owing to injuries incurred during delivery. 

Symptoms. — The symptoms depending on congenital atelectasis vary 
a good deal in different cases. There are some, however, which exist 
in most instances. These are the following: the child comes into the 
world feeble and weak, and instead of crying vigorously and loudly 
the moment or very soon after it is born, it fails to cry at all, or the 
cry is low and weak, or it is whimpering or wailing; the color, instead 
of being brick-red or dark-red, is pale and whitish, leaden, or livid ; the 
muscular movements, which, in healthy children, are strong and vigor- 
ous, are in these, languid and slow, or there are none or scarcely any, the 
limbs being relaxed and motionless. If the breathing is observed, it is 
found to be short, high, and imperfect, and it is evident that the thorax 
is but imperfectly dilated at each movement of respiration. When 
these symptoms exist in a very marked degree, the infant either dies 
soon in a state of asphyxia, or, the muscular force slowly increasing, 
the respiration gradually improves, and the child is, after a longer or 
shorter time, either out of danger, or it falls into the same state as that 
of one in whom the symptoms have been from the first less severe. 
Under the latter circumstances, the infant continues feeble and weak. 
It breathes shortly, rapidly, and imperfectly, but often without any 
appearance of effort. The cry is rare, and when heard, is low and fee- 
ble, or there is with each respiration a constant plaintive moan, which 
is very characteristic, and strongly expressive of exhaustion. The 
color continues pale and whitish, or it is bluish, and the temperature 
of the extremities is lower than natural. The child sleeps the greater 
part of the time, and is unable to nurse or nurses very feebly, but can 
swallow when fluid is poured into the mouth. In such cases as these, 
the infant does not necessarily die, but will often recover when properly 
treated. In favorable cases, the symptoms just enumerated may last 
from a few hours to a day or two, or even a few weeks, without much 
change • then, under the influence of correct hygienic and medical treat- 
ment, they will often begin to improve. The color becomes less pale 
or less bluish; the muscular movements are somewhat stronger ; the 
child begins to cry, and in a louder tone ; the act of swallowing is easier 
and more perfect, or the infant is able to suck when applied to the 
breast, at first feebly and only for a moment, and then more stronglj-; 
the respiration becomes slower, fuller, and more natural, and gradually 
the dangerous symptoms disappear. 

In unfavorable cases, on the contrary, the respiration fails to improve, 



138 COLLAPSE OF THE LUNG IN EARLY WEEKS OF LIFE. 

but becomes more and more short, quick, and imperfect; the tempera- 
ture of the body falls; the color of the surface changes, becoming leaden, 
bluish, or even livid, the change showing itself first in the neighborhood 
of the mouth, and in the hands and feet, and extending gradual!}^ to 
the rest of the body; the difficult}^ in swallowing becomes greater^ and 
very generally some spasmodic twitchings begin to show themselves 
about the muscles of the face. The respiration is very often attended 
with slight wheezing or rattling, and the convulsive movements return- 
ing frequently, and becoming more violent and more general, the child 
dies in convulsions, or it sinks very slowly and gradually, without con- 
vulsions, as though in a state of syncope. According to Steffen (Klinik. 
d. Ki7iderh\, 1865, 1 Bd., p. 50), thrombosis of the cerebral sinuses has 
been found after death under such cojpditions. 

There is another symptom of imperfect expansion of the lungs in 
new-born and very young infants, which ought not to be passed un- 
noticed. It is one mentioned by Dr. George A. Eees of London, in 
an essa}^ on this subject (London, 1850), and is of much diagnostic 
value, although not a pathognomonic symptom of this condition as re- 
garded by him. It is an altered movement of the ribs in respiration. 
During the inspiratory effort the ribs are seen to move inwards toward 
the mesial line of the trunk, instead of outwards as in ordinary respira- 
tion, thus diminishing instead of expanding the transverse diameter of 
the thorax. The explanation of the altered movement is as follows: 
when the diaphragm descends, the lung ought to expand in such a way 
as to fill up the increased space produced in the thoracic cavity by the 
descent of that great muscle. Instead of this being the case, however, 
the lung is collapsed and inexpansive, and cannot enlarge sufficiently 
to fill up the space alluded to, so that there would remain a vacuum in 
the chest were it not that the thoracic walls are driven inwards by the 
pressure of the atmosphere upon their outer surface. In a case that 
we saw ourselves in a child fourteen months old, who had presented 
symptoms of atelectasis from birth, and in whom we found after death 
very extensive collapse, this symptom was very marked. The base of 
the thorax was indented on both sides by a deep gutter or depression, 
which remained depressed and unchanged during the inspiratory move- 
ments, or which, indeed, rather became more distinctly visible during 
those motions, so that the chest presented the curious spectacle of dila- 
tation or expansion in its upper parts, during inhalation, and of contrac- 
tion or collapse at its base. 

In regard to this interesting sign the reader is referred to our article 
on rickets, where is mentioned the explanation given of it by Jenner, 
in connection with the latter disease. 

Symptoms of Collapse in the Early Weeks of Life. — Before tak- 
ing up the regular consideration of post-natal collapse, as it occurs at 
all ages of childhood, we wish to refer, for a moment, to that condition 
as it appears in the first few weeks of life, in infants who have exhib- 
ited no sign of it whatever, perhaps, at the moment of birth. We de- 
sire to do this now, because the symptoms to which it gives rise re- 



SYMPTOMS. 139 

semble much more those of congenital atelectasis, than those of collapse 
in childi'en over a few months old. And let it be remarked that these 
symptoms are very different, and much more severe and threatening 
than those of collapse at later periods. They are in fact those of cya- 
nosis, and, in some instances, are as strongly marked as those observed 
in the worst cases of that condition, caused by malformation of the 
heart or great vessels. The cyanosis and other symptoms of disordered 
circulation, evidently depend on the obstacle offered by the collapsed 
and condensed portions of lung-tissue to the discharge of blood from 
the right side of the heart. Though this obstacle to the venous circu- 
lation is doubtless the chief cause of the symptoms in these cases, we 
cannot but think ourselves, that the great difference between the symp- 
toms of congenital atelectasis, as well as of post-natal atelectasis occur- 
ring in the first few weeks of life, and the collapse of later periods, 
must be explained in part, at least, by the fact that the foetal openings, 
the foramen ovale, and ductus arteriosus, and especially the former, 
are still patulous, or in such a condition that they may be reopened 
under pressure, and so allow a portion of the contents of the overloaded 
and congested right side of the heart to pass into the left auricle, thence 
into the left ventricle and aorta, and so to the whole body. 

In this form of atelectasis, the child may have been born perfectly 
healthy, or only weaker than usual, or it may have had some difficulty 
in establishing the respiration, which, however, has afterwards been 
effected in the most complete manner. Some days, or even weeks 
after birth, from a cause disturbing the function of respiration, por- 
tions of the lung may collapse, and give rise to the different s^^mptoms 
of that condition in the manner above described. The most important 
of these symptoms are difficulty of breathing, consisting either in an 
increased or diminished rate of that function, diminution of the mus- 
cular power, cyanotic hue of the skin, and slight or severe spasmodic 
phenomena. In a case that occurred to one of ourselves (see Am. Journ. 
Med. Sc, loc. cit.), a child who had exhibited at birth, and for five days 
after, every appearance of fine health, was observed on the sixth day 
to cry rather violently in the morning. At one o'clock in the day he 
began to moan, and appeared distressed; at two he ceased to moan, 
became bluish, and seemed to lose his breath. He was placed in a bath, 
in which the blueness passed off, but the breathing continued irregular 
and uneven. He soon became blue again, and breathed- slowly and 
irregularly, but had no spasm. At about four o'clock another paroxysm 
occurred, in which the whole surface became first bluish, and then 
dark, while, at the same time, the trunk and limbs became stiff and 
rigid under the influence of tonic muscular spasm, and the respiration 
was slow and imperfect. After the attack had lasted for some moments, 
the blueness and spasmodic phenomena disappeared, but the child re- 
mained in a state of stupefaction. There were two slight paroxj^sms 
of convulsive stiffening between this and evening, and later in the even- 
ing there was still some blueness, with irregular and short respiration. 
During the night the breathing was short and uneven^ and attended 



140 ATELECTASIS PULMONUM. 

with moaning, but on the following da}' the symptoms had disappeared 
entirely, and there was no return. 

In another case the symptoms of collapse did not appear until the 
twenty-fifth day after birth. The infant had been hearty and strong 
at birth, and had established its respiration fully and completely. Be- 
tween the birth, however, and the time of the attack, circumstances 
connected with the lactation had caused the development of diarrhoea 
with thrQsh, which had debilitated the child a good deal. On the day 
of the attack, frequent sneezing, with stuffing of the head, and some 
cough, seemed to show the existence of catarrh, and, on the same day, 
the child was unfortunately exposed, owing to the accidental opening 
of one of the gas-burners, to the inhalation of some gas. Late in the 
evening, a slight whistling or stridulous sound was heard in the breath- 
ing, the skin became suddenly a little bluish, and a slight convulsion 
followed. During the night there were frequent and strong convulsive 
seizures, always preceded and followed by deep blueness of the mouth, 
hands, and feet, and it was noticed that the least disturbance, as lifting 
or nursing, or changing the position, always brought them on. The 
next morning the attacks continued, but with diminished violence, 
under the effects of treatment, and they ceased after the middle of the 
day. The color of the skin had now changed; it had become rosy red, 
instead of pale or blue, and the hands and feet, which had been cold, 
were now warm and natural. There was no return after this. 

In a third case a female infant, who had been perfectly well at birth 
and up to the moment of this attack, was put suddenly into a bath by 
the nurse on the eighth day, directly after its waking from sleep. The 
child, who was not thoroughly waked up, seemed greatly terrified, and 
began to scream most violently. Instead of removing the infant from 
the water, the nurse persisted in holding it immersed for some minutes, 
when it became deeply blue, and partially convulsed* it frothed at the 
mouth and nose, seemed to be suffocating for breath, and appeared to 
be dying. These symptoms continued for three-quarters of an hour, 
when they graduallj' passed away, and it fell into a heavy sleep. When 
we saw the infant, soon after this, the only signs of disorder that re- 
mained, consisted of an unusual paleness, drowsiness, and an expression 
of feebleness. Some three hours later, it waked, nursed, and from that 
time seemed quite well. 

In a fourth case, a child born apparently well, with the exception of 
its having had a rather frequent respiration, and who nursed very well 
on the second and third day, was attacked on the fourth day with blue- 
ness, moaning, short and panting respiration, and then with slight con- 
vulsive symptoms. It was unable to nurse, and though kept perfectlj' 
still, and fed from time to time with small quantities of milk and 
brandy, became gradually more deeply blue, had paroxysms of very 
slow respiration and circulation, with general convulsive seizures, and 
died at the end of twenty-four hours. 

The reader will also find this form of cyanosis referred to in our 
article on that disease. 



DIAGNOSIS — PROGNOSIS. 141 

Diagnosis. — There can be no difficulty in detecting the nature of the 
case when the imperfect expansion exists from birth, and when the 
physician is present at that event. 

When, however, coUapse of the hmg-tissue continues after birth, and 
the physician is called upon to determine, at the age of some days, 
weeks, or even months, the cause of the feeble health and puny growth 
of the child, or to explain those sudden attacks of collapse in very 
young infants who had previously well established, to all appearances, 
the respiration, the diagnosis becomes more difficult. In the former 
class of cases, attention to the following points will usually, however, 
enable us to make a correct diagnosis. The previous history is par- 
ticularly important, since, in all such cases, it will be found that the 
infant was either still-born and resuscitated with more or less diffi- 
culty, or that it was born weak and feeble, and that the respiration had 
not been established as thoroughly and completely as it ought to have 
been. Dr. Eees states that certainly half of the cases of this form, in 
his own practice, occurred in twins, and that they were all born in a 
more or less completely asphyxiated condition. The present symptoms 
are also very important. The feeble appearance of the child, and its 
puny growth^ in connection with its past history, and the absence, as 
ascertained by careful examination of the case, of other morbid condi- 
tions to explain the general ill-health, ought to direct the attention of 
the physician to the true nature of the disease; and if we add to these 
considerations the local thoracic symptoms, the short, rapid and im- 
perfect breathing, with, perhaps, the altered movement of the ribs, the 
indentation instead of expansion during inspiration, mentioned above; 
the absence of fever; and the existence of the physical signs of more 
or less extensive solidification of the pulmonary tissue, without those 
of pneumonia; there will seldom be any difficulty in forming a correct 
diagnosis. 

The cases described under the head of collapse in the early weeks of 
life may be readily understood from the simple fact that the symptoms 
cannot be satisfactorily explained by referring them to any other con- 
dition than that of collapse of portions of the lung, with impeded and 
deranged circulation. 

Prognosis. — The condition of impei^foct expansion of the lungs in a 
new-born child, does not necessarily cause it to die immediately or very 
soon after birth. The fate of the child will depend very much upon 
the cause of the atelectasis, upon its degree of innate strength and 
vigor, and upon the kind of hygienic conditions to which it may be 
consigned. When the child is well developed, and not enfeebled by any 
fault in the mother's health during the pregnancy, but merely by some 
momentary condition that has occurred during the labor, there is every 
reason to hope thatpro.per hygienic and medical treatment may restore 
it to health. The danger is greatest in those who continue weak and 
feeble, in spite of the proper measures of care and treatment, for some 
days or weeks after birth. We have a record of ten examples of this 
condition in new-born children, in nine of which the symptoms per- 



142 ATELECTASIS PULMONUM. 

sisted during a period varying between six hours and five daj^s. Of these, 
seven lived, while three died in from twenty-one hours to three days. 

The prognosis of the second class of cases — those in which collapse 
occurs suddenly a few days or weeks after birth, and after the ap- 
parently complete establishment of respiration — will vary, of course, 
with the violence of the symptoms. Of five cases of this kind that 
came under our observation, recovery took place in three in spite of 
the most dangerous and alarming symptoms, while in two death oc- 
curred in a period of about twenty-four hours. 

In cases where the collapse of the lungs has been extensive, and has 
in part persisted without proving fatal, serious organic changes in the 
heart have been found to follow, both by F. Weber and Steffen. The 
long-continued obstruction to the pulmonary circulation prevents the 
closure of the ductus arteriosus, and subsequently causes hypertrophy 
with dilatation of the right side of the heart, a patulous state of the 
foramen ovale, and at last eccentric hypertrophy of the left auricle and 
ventricle. Undoubtedly, in most cases, death occurs before these 
changes in the heart are induced, but it is important to be aware that 
imperfect expansion of the lungs may thus serve to develop serious car- 
diac disease of a form likely to be attended with cyanosis. 

When the imperfect expansion depends upon the presence of accu- 
mulations of mucus in the air-passages, well-directed efforts usually suc- 
ceed in effecting the removal of the obstruction, and the establishment 
of free inspiration. In those cases, finally, where there is pressure 
upon the pneumogastric nerves near their origin, a fatal result must 
always follow. 

Treatment. — The treatment of congenital atelectasis must be di- 
rected to the removal of its probable cause. If this is suspected to be 
obstruction of the air-passages by collections of mucus, the infant's 
mouth should be cleansed, and vomiting provoked by tickling the 
fauces. In addition to this, all the measures calculated to stimulate 
respiration should be employed. 

When the imj^erfect expansion appears to depend merely on the 
weakness of the infant, the treatment resolves itself almost entirely 
into the employment of such means as tend to invigorate the general 
health of the child, and to promote the activity of the respiratory act. 
In a recent case, one dating from birth, in which the function has al- 
ways been imperfect, and in which there are present great feebleness, 
drowsiness, and paleness or blueness, the room in which the infant is 
placed should be kept up to a temperature of 70° or 75°, and the child 
should be abundantly covered with warm clothing. Perfect quiet, or 
at least very gentle motion, is very important, and when there is any 
disposition to deep blueness or to convulsive movements, attention to 
this point is essential. It is in such cases, and in those in which these 
symptoms come on a few days or weeks after birth, that the position 
recommended b}^ the late Dr. C. D. Meigs, for the treatment of cyanosis 
neonatorum, was found by him so useful. This position is one upon the 
right side, with the head and shoulders raised at an angle of 45°. It is 



TREATMENT. 143 

obtained l\v arranging pillows in such a way as to form a plane inclined 
at that angle. Upon this the infant is placed, and orders are given that 
it is not to be moved at all, if possible, or only with the greatest care 
and gentleness, for twenty-four or forty-eight hours. There can be no 
doubt that this position and the attendant repose have, in many cases 
recorded by Dr. C. D. Meigs, and in several that we have seen our- 
selves, been of very great use in controlling the symptoms. Its good 
effects in cyanosis were supposed by him to depend on the fact that the 
septum auricularum becomes horizontal in this position of the body, so 
that the blood in the right auricle must rise against gravity, in order 
to pass through the foramen ovale, while, at the same time, the valve 
of that opening is disposed to fall down hy its own weight, and close 
the foramen, and is, moreover, pressed downwards by any blood that 
may enter the left auricle from the pulmonary veins. This explanation 
will apply, of course, only to those cases of atelectasis accompanied by 
very extensive and deep bkieness or purple color of the surface, in 
which we may suppose that so much of the pulmonary tissue is solidi- 
fied, as to produce a degree of obstruction to the passage of blood from 
the right side of the heart into the lungs, sufficient to overload the 
right ventricle and auricle, until the latter pours a portion of its con- 
tents into the left auricle, thus causing admixture of the two kinds of 
blood. In a large majority of the cases of atelectasis, however, this 
explanation of the benefit resulting from the treatment referred to, 
cannot be received, as there is no reason to suppose that in them the 
slight cyanotic symptoms present indicate anything more than the ex- 
istence of a moderate degree of congestion of the right side of the 
heart, unattended by any escape of blood from the right into the left 
auricle. In such cases the position on the right side is useful, because 
it is the one most favorable to a full and easy performance of the respi- 
ratory and circulatory functions. It leaves the left side free and unem- 
barrassed, so that the heart can act with the greatest possible freedom, 
while the partial elevation of the head and shoulders renders the move- 
ments of the chest more easy and complete than when the body is lying 
on a horizontal surface. The perfect quiescence which constitutes a 
part of the treatment is also very important, as in many recent and 
particularly in cyanotic cases, the symptoms are greatly aggravated, 
and convulsive attacks often brought on by moving the child, especially 
if this be done suddenly or rudely. 

Yarious means are also recommended for rousing the force of respi- 
ration, as by compelling the infant to cry, by frictions of the surface, 
by plunging the body alternately into warm and cool water, or by al- 
lowing a stream of cold water to fall on the nape of the neck with the 
view of exciting the respiratory nerve-centres. 

Attempts may also be made to produce full inflation by gentle mouth- 
to-mouth respiration. The other modes of attempting to accomplish this 
are either (as by compressing the thorax at regular intervals) of but 
little value, or (as in case of Hiiter's proposal to inflate the lungs after 
catheterization of the larynx) highly objectionable. 



144 COLLAPSE OF THE LUNG. 

Perhaps the most important point of all in the treatment of this 
affection, especially when the symptoms tend to become persistent, is 
the mode of nutrition of the child. If possible, the infant should al- 
ways have a good breast of milk, and if unable to suck, the milk ought 
to be drawn by means of a breast-pump, and given to the child in small 
quantities from a spoon. About two or three teaspoonfuls may be 
given at first every half hour or hour, and the quantity gradually in- 
creased until the child gains strength enough to be put to breast. If 
breast-milk cannot be procured, cow's milk and water may be substi- 
tuted, in the proportion of one part of the former to two or three of the 
latter. The only medicines to be given are, at first, while the child is 
still very young and weak, mild stimulants, of which the best, in our 
opinion, is fine old brandy. Of this about five drops may be given each 
time that the milk is taken 3 or, we may make use of from three to five 
drop doses of the aromatic spirit of hartshorn, or of proper quantities 
of wine-whey. 

When the symptoms of congenital atelectasis tend to persist for 
several weeks or months, or when we first see the patient some time 
after birth, the chief points to be attended to in the treatment are, as 
before, the mode of nutrition, which ought to be by nursing and the use 
of gentle stimulants and tonics. Brandy, wine, or Huxham's tincture 
of bark, are the best stimulants ; whilst quinine, in the dose of a quar- 
ter or half a grain, three times a day 3 extract of cinchona, in the dose 
of from one to three or four grains, three times a day; or iron in the 
form of Quevenne's powder, or in that of the iodide, are the best tonics. 

Yogel {Dis. of Children^ Amer. ed., 1870, p. 55) speaks very highly of 
the advantage derived from the cautious application of electricity to 
the pectoral muscles. 

COLLAPSE OF THE LUNG, OR POST-NATAL ATELECTASIS. 

General Remarks. — By collapse of the lung is meant the return of 
that organ to its foetal or unexpanded state. It is in fact a condition 
of atelectasis or imperfect expansion of its vesicular structure. The 
terms collapse or post-natal atelectasis are employed to contradistin- 
guish it from congenital atelectasis, the former being applied to imper- 
fect expansion as it occurs in lung-tissue after previous expansion, and 
the latter, as stated in the preceding article, to the same condition as , 
it exists in children who have never expanded certain portions of the 
pulmonary substance. 

The true nature of collapse of the lung was never understood, and 
its great practical importance never appreciated, until since the year 
1844, when MM. Legeudre and Bailly published, in the Archives Gener- 
ales de 3Iedecine, their researches on the subject. Since then various 
observers have repeated the investigations of those gentlemen, and 
thrown new light upon the matter. Among the most important of the 
later writers on this subject, we may mention Dr. Charles West of 
London, MM. Hardy and Behier of Paris, Dr. W. T. Gairdner of Edin- 



GENERAL REMARKS. 145 

bnro:h, and M^I. Eilliet and Barthez, in the second edition of their 
work. 

This discovery in pathology was one of very great value, not merely 
because it renders our knowledge of the morbid conditions of the lungs 
more exact and philosophical than it ever was previously, but because 
it explains certain anatomical changes in the pulmonary structures, 
often before noticed and described, but never satisfactorily accounted 
for; and still more, because it points to methods of treatment much 
more rational and much more successful than those employed under 
the influence of former ideas as to the nature of the lesions alluded to. 
The most important result of the new views is the disclosure of the 
fact that several lesions met with after death, which were formerly 
thought to depend on inflammation of the afi'ected tissue, are in reality 
the consequences of collapse or obliteration of the vesicular structure 
of the lung, and not of inflammation, as was at one time supposed. 
The lesions alluded to are those w^iich have been hitherto described 
under the names of lobular pneumonia and carnification. 

The peculiar character of the lesions met with in many of the sup- 
posed cases of pneumonia, had often attracted attention and been com- 
mented upon, before their real nature came to be understood. The 
points of difference between these alterations and those of true pneu- 
monia were particularly noticed by MM. Denis, De La Berge, Eufz, 
Rilliet and Barthez, Dr. Gerhard, and Dr. West. In fact, M. Eufz, and 
MM. Eilliet and Barthez, both approached very near the truth in re- 
gard to these lesions, each comparing them, but the former at an ear- 
lier period than the latter, to the condition of the lung of a foetus that 
has never breathed. The latter writers, in the article on pneumonia 
in their first edition, have described a condition of the lung which dif- 
fered so much from ordinary pneumonia as to create a great difficulty 
in their minds as to its true nature, and to it they applied the term 
carnification. They were on the very verge of detecting its real char- 
acter ; they did in fact suggest its real character, but were so possessed 
with the idea that it must be the result of some inflammatory action 
as to neglect to pursue their own suggestion, but endeavored to explain 
the condition on the ground that it was "one mode of termination of 
pneumonia, or else chronic pneumonia." The following passage, quoted 
from their work (lere ed., t. i, p. 74), will show how closely they ap- 
proached the truth : " The first idea that enters the mind on examin- 
ing this tissue (carnification) is, that it resembles the lung of a foetus 
that has not breathed; we should feel inclined to say that the pulmo- 
nary vesicles had not yet been dilated under the influence of the tho- 
racic expansion, and had not, therefore, admitted air into their interior; 
or, rather, it would seem as though they had been obliterated by some 
attack of disease, perhaps inflammation, without, however, remaining 
engorged, and after having lost the power of dilatation." 

In the second edition of their great work, MM. Eilliet and Barthez 
adopt, in great measure, the views of MM. Legendre and Bailly, and of 
Dr. Gairdner, not only in regard to carnification, but also in regard to 

10 



146 COLLAPSE OF THE LUNG. 

the yet more important lesion hitherto generally called lobular pneu- 
monia. 

But it is not only the condition of the lung called carnification that 
has been shown to consist, not in inflammation, but in a collapse of the 
pulmonary tissue. A much more important consequence of the recent 
researches has been the discovery that in a very large majority of 
cases the so-called lobular pneumonia, generalized lobular pneumonia, 
and pseudo-lobar pneumonia of different writers, are also the results of 
collapse of the lung, variously combined with bronchitic inflammation 
and congestion of the pulmonary tissue. The latter discovery has 
lessened ver}^ much the importance of pneumonia as a disease of early 
life, while it has augmented in the same proportion that of bronchitis, 
for it has shown that a very large number of cases, formerly regarded 
as true inflammation of the parenchyma of the lung, are in fact cases 
of bronchitis combined with collapse of the tissue of the organ. 

Now that the nature of collapse of the lung, in connection with bron- 
chitiS; and sometimes, also, with true ]3neumonic inflammation or con- 
gestion, has been made known, a number of symptoms occurring in 
the pulmonary affections of children, which formerly seemed obscure and 
irregular, have become easily explicable. It had been often observed 
that many of the supposed pneumonias of children did not present the 
same symptoms, pursue the same course, nor require the same treat- 
ment as the pneumonia of adults, or as some cases of the disease in 
children. In a great many of the supposed cases there was an unusu- 
ally large amount of bronchial inflammation, the general s^'mptoms 
were much less acute than was to be expected in a parenchymatous 
inflammation, and what was most singular of all, the physical signs of 
solidification of the lungs were very variable and uncertain, there being- 
present on one day the signs of simple bronchitis, while on the same 
day or the following, and over the same region of the thorax, these 
would be associated with or masked by the signs of induration of the 
lung; and again, in a day or two, the s^^mptoms indicative of condensa- 
tion might disappear, to be succeeded yet again by those of simple 
bronchial inflammation. The effects of treatment seemed also to point 
clearly to a radical difference between the lobular or broncho-pneu- 
monia of children, and the acute phlegmasial disease of adults. It was 
found, in fact, that depletory measures were seldom borne well in the 
lobular pneumonia of children, while in the pneumonia of the adult, 
and in some acute cases occurring in early life, which presented the 
same general symptoms and the same physical signs as pneumonia in 
the adult, antiphlogistics, as is well known, are amongst the most suc- 
cessful remedies that can be made use of. • 

Anatomical Lesions. — Collapse of the lung (post-natal) occurs in 
two different forms, the diffused^ and the limited or lobular. The only 
difference between the two forms is in the number of lobules affected, 
and their mode of distribution. In the diffused variety, a large num- 
ber .of adjoining lobules collapse, and give a condensed and solid appear- 
ance to larger or smaller portions of the lung, most frequently to the 



ANATOMICAL LESIONS. 147 

edges merely of one of the lobes, but at others to the greater part or 
the whole of a lobe, or even the major part of a lung. In the lobular 
variety, on the contrary, single lobules or clusters of lobules become 
collapsed in different parts of a lobe or lung, and the affected portions 
take the form of irregular hardened patches or tumors, situated upon 
the surface, or disseminated through the interior of the pulmonary tex- 
ture. In the former kind of collapse, the appearance of the altered 
portion of the lung is somewhat that of lobar pneumonia, and it is to 
these cases that the terms generalized lobular, pseudo-lobar, carnifica- 
tion, and splenization, have been applied; while in the latter kind, the 
isolated and distinct condensed portions have been described by the 
term lobular pneumonia. 

The peculiar or fundamental characters of collapsed pulmonary tissue 
are the same in both varieties. We will mention them as succinctly as 
possible, and then compare them with those of pneumonia, for the reason 
that it is with the lesions of that disease that those of collapse have been 
so frequently confounded. 

Colla23sed lung is generally of a dark violet color, but it may be much 
darker in tint, and even black, when it is much engorged with blood. 
Its consistence is always changed ; the condensation may amount merely 
to slight hardening, w-ith a diminution of the crepitation, or it may be 
very dense with an entire absence of crepitation, in which case portions 
thrown into water sink rapidly. Though more or less hardened, the 
tissue still retains a certain degree of flaccidity and suppleness. When 
cut into, the surface is seen to be smooth and uniform, having some- 
what the appearance of muscle, and presenting no granulations. Pres- 
sure or scraping cause the exudation of more or less semi-transparent 
bloody serosity. Close examination shows that the organic elements of 
the tissue, the vessels, bronchia, cellular tissue, &c., can still be dis- 
tinctly traced. Lastly, inflation of the lung distends the condensed 
parts, and gives to them again, more or less completely, their natural 
physiological characters. 

MM. Eilliet and Barthez, in their second edition, treat, at considera- 
ble length, of congestion of the lung as a very constant accompaniment, 
and as a very important element in the state of collapse. They regard 
this congestion as being connected nearly always with bronchitic in- 
flammation, and as being not merely a passive state, but as exhibiting 
phenomena, in most instances, which prove it to be in some degree an 
active condition. They say {op. cit., t. i, p. 428) : " We readily acknowl- 
edge that a state of debility, prolonged dorsal decubitus, and the ob- 
struction to the circulation thus occasioned, facilitate the jDroduction of 
this condition, and give to it the appearance of a simple passive conges- 
tion. But we believe that there exists, moreover (frequently, if not 
always), a really active and even inflammatory movement." The}" re- 
gard this opinion as proved chiefly by the fact that they have found 
the texture of the affected parts to be somewhat softened, as shown by 
the facility with which they are torn by the finger or by scraping with 
a scalpel ; by the swelled and turgid condition the tissues exhibit; by 



148 COLLAPSE OF THE LUNG. 

the quantity of sanguineous or sero-sanguiueous liquid which escapes 
on pressure; and by the presence of a serous exudation around the 
pulmonary vesicles, while the interior of the vesicles appears to be 
healthy. The last-mentioned condition the}' found upon their own ob- 
servation, and upon a microscopic examination made by M. Lebert. 

The color is different in the two alterations ; being, in collapse, purple 
or livid, and, in pneumonia, brownish-red or fallow-red. In pneumonia 
the pleura covering the hepatized portions is often covered with false 
membrane, showing thereby the inflammatory nature of the disease; 
in collapse this is rarely the case, and only when there is some acci- 
dental concomitant pneumonia. The density of the lung in the two 
conditions is of a different kind: in pneumonia it is hard to the touch, 
and unyielding: in collapse it always retains a certain degree of flac- 
cidity and softness, like that of muscular tissue. In pneumonia the 
diseased part is turgid and swelled, so that it projects above the com- 
mon level of the surrounding surface; in collapse, on the contrary, it is 
shrunken and depressed below the neighboring parts. In pneumonia 
the effect of the inflammatory process on the tissues is very strongly 
marked, and produces changes in them very different from those occa- 
sioned by mere collapse. In the former disease the cohesive properties 
of the pulmonary structure are very much lessened, so that the inflamed 
parts are readily penetrated by the finger, and are easily torn; in simple 
collapse, on the contrary, the diseased part is as firm and resisting, or 
even more so, than in health; whilst in collapse occurring in bronchitis 
and attended with congestion, though the cohesion of the tissues is 
somewhat lessened, it is never nearly so much so as in pneumonia. In 
the true hepatization of pneumonia, a cut surface always presents a 
granular aspect, while in collapse, on the contrary, it is smooth and 
even. On scraping a cut surface it is found that, in the former altera- 
tion, a plastic, fibrinous matter, of a yellowish, orange, or gray color, 
comes off on the knife; while, in collapse, only some semi-transparent 
bloody serosity is scraped off. In the former, the anatomical arrange- 
ment of the lobules cannot be seen, as the inflammation attacks indif- 
ferently the lobules themselves, the interlobular septa, and parts of 
neighboring lobules; but, in the latter, the alteration can always be 
seen to be more or less regularly confined to the lobules, the cellular 
interstices between the lobules remaining more or less apjDarcnt; so 
that in pneumonia the alteration is not bounded at all by the outlines 
of the lobules, while in collapse the alteration always affects, more or 
less, the lobular form. To conclude, the effects of inflation are altogether 
different in the two conditions. M. Legendre (Becherches Aiiatom.-Path. 
et Clin, sur quelques Mai de VEnfance^ p. 164) states that air can never 
be made to penetrate by inflation into a completely hepatized lung. 
Neither in hepatization of the lobar form, nor in true partial hepatiza- 
tion, has he ever been able, even with the utmost effort, to push air 
into the inflamed tissues. After repeated trials, the tissue remained 
compact and friable, and sank as rapidly as before when thrown into 
water. In the foetal state, on the contrary, the slightest effort sufiiced 



CAUSES. 149 

to fill aud distend the collapsed air-cells, and to give to the altered por- 
tion its natural appearance, excepting that it became more red in con- 
sequence of the oxygenation of blood contained in the capillaries. Dr. 
Gairdner (^Pathol. Anat. of Bronchitis, c&c, Edinburgh, 1850, pp. 18, 14) 
reraarixs that, though this test "is very useful in demonstrating the 
nature of the lesion, in a favorable case, to one not familiar with its 
character, I do not believe it to be applicable to the determination of 
the presence or absence of pneumonia in those mixed cases in which 
alone there is any difficulty." He has observed, in fact, that partially 
pneumonic lung may be inflated when the affection is recent and com- 
bined, as it frequently is, with bronchitic collapse, while in the latter 
lesion, in its purest forms, complete inflation is often very difficult or 
impossible after the collapsed state has been of some duration. 

The part of the lung in which collapse is most frequentlj" met with, 
depends somewhat on the form of the alteration. In the diffused vari- 
ety, it ma}^ affect a more or less considerable portion of either or both 
lungs, but is most common at their posterior part. The lobular variety 
is most common on the anterior edges, but may, like the diffused, occur 
in any other part. As a general rule, the alteration is most frequent 
at the periphery of the organ, where its edges are thin, as along the 
margins of the lobes, in the languette of the upper lobes, and at the 
bases of both lungs. The parts just named are those most distant from 
the primary air-passages; they are those in which the inspired air 
would arrive last, and with the least force of impulsion. 

Causes. — It has been generally acknowledged that there are two 
principal causes by which to explain the production of collapse of the 
lung. These are the presence in the bronchia of some condition which 
acts as an impediment to the ready passage of the inspired air, and 
a want of power in the muscular apparatus by which the function of 
respiration is carried on. To these Dr. Gairdner adds another, — the 
inability to cough and expectorate, and thus remove the obstructing 
mucus, — but this is, in fact, included in the preceding. 

The most important of the above-mentioned causes is evidently the 
deficient respiratory power, since this is noticed and insisted upon by 
all observers. It has been found, in fact, that collapse seldom occurs 
to any considerable extent except in children who are exhausted and 
debilitated. The debility may be congenital, it may be the result of 
wearing diseases, as diarrhoea, hooping-cough, measles, typhoid fever, 
&e., or it may depend on exposure to unwholesome and enfeebling hy- 
gienic conditions. It is easy to understand that a child who is either 
born weak and feeble, or who becomes so in after years from any of 
the causes just alluded to, must lose, with the general decay of the 
strength of the body, some portion of the muscular power by which 
alone a complete and efficient dilatation of the thoracic cavity can be 
accomplished, and that, when this is the case, the inspirations must be 
short and imperfect, and that portions of the lung most distant from 
the primary air-passages, not being reached by the inspired air, will 
remain in an unexpanded or collapsed state. If we add to this state of 
feeble respiratory power^ the presence of opposing secretions in the air- 



150 COLLAPSE OF THE LUNG. 

tubes, whether these be the consequence of bronchial inflammation, as 
they are in the immense majority of cases, or, as Dr. Gairdner suggests 
they may sometimes be, the mere natural secretion of these tubes, ac- 
cumulated for the want of power to throw them off, it becomes abun- 
dantly easy to comprehend the mode of production of collapse, in at 
least some of the examples. 

Whether a simple deficiency of inspiratory force alone, without ob- 
structing mucus in the bronchia, will give rise to collapse, is a some- 
what mooted point. Dr. West agrees with MM. Legendre and Bailly, 
in the opinion that it is often due to the inspiratory power having been 
inadequate to overcome that natural elasticity of the lung which opposes 
a full dilatation of the organ. Dr. Gairdner {loc. cit., p. 33) cannot 
'' see reason to believe with Dr. West, that mere debility, apart from any 
obstruction in the tubes, is a sufficient cause for collapse in the child." 
He remarks, and with strong show of reason, that the very fact of the 
lesion being usually more or less lobular, or partial in its distribution, 
appears to indicate special circumstances of a local kind, as having a 
marked influence on the production of this aff'ection. What is of most 
consequence, however, to the working physician, as an important prac- 
tical truth, is the fact stated by several observers^ and adverted to by 
Dr. Gairdner himself, that in some cases no signs whatever of obstruc- 
tive bronchitis or of bronchial accumulation can be discovered during 
life. Before leaving this point, we desire to call attention to the opinion 
of Hasse (Pathol Anat., Syd. Soc. ed., p. 258), that, though this partial 
introduction of air might be deemed at variance with the laws of res- 
piration, inasmuch as the atmospheric pressure must necessarily dis- 
tend the entire lung equall^y, not to the exclusion of a lobe, and still 
less to that of a lobule, the objection falls to the ground when it is con- 
sidered that the operation of these laws is the result of previous muscu- 
lar action. He refers to the fact that in pleurisy one-half of the thorax, 
and in partial pleurisy certain portions of that cavity, do not share at 
all in the movements of the remainder. " We need, therefore," he says, 
" be at no loss to understand how defective breathing may originate 
in a merely partial activity of the intercostal or other respiratory 
muscles." 

Dr. Gairdner, as already stated, considers as one of the causes of col- 
lapse, an inability to cough and expectorate, and thus to remove the 
obstructing mucus. The views which he expresses on this point are 
very interesting, and also, we think, very important. He states that 
Laennec supposed the expiratory force of respiration to be weaker than 
the inspiratory, while in fact the experiments of Hutchinson and Men- 
delsohn, to which he refers, prove that though ordinary inspiration 
is more of a muscular act than ordinary expiration, yet the residual 
effective force for overcoming adventitious obstruction is very con- 
siderably greater in expiration. ''The forced or muscular expiratory 
act is, in ftict, about one-third more powerful, as measured by its 
effect upon a pressure-gauge, than the extreme force of inspiration; 
and it is this force which is thrown into action when obstruction 
in the tubes is to be overcome." In the act of coughing, the air in 



SYMPTOMS. 151 

the vesicles is brought to bear upon the obstructing substance within 
the bronchia, at a maximum amount of outward pressure, and with the 
additional mechanical advantage of a sudden impulse, so that the prac- 
tical efficiency of the expiration in forcing air through obstructions 
must be far greater than that of inspiration. It is clear, therefore, 
that if the secretions in the air-passages be so abundant or so viscid as 
to interfere materially with the entrance and exit of air, they must 
necessarily occasion collapse, either partial or total, of the parts be- 
yond them, since not only does the air enter with difficulty, but being 
expelled with greater force and in larger quantity than it can be drawn 
in, the amount remaining in the vesicular structure must gradually 
diminish. This effect of obstruction will be still more remarkable when 
the muscular force of respiration is diminished by debility of the patient, 
for then the inability of the inspiratory act to replace the air driven 
out b^ expiration, will be yet more marked than when the muscular 
powers of the body retain their full force. 

There is still another mechanical condition which tends to produce 
collapse from obstruction, to which Dr. Gairdner refers. This condi- 
tion is to be found in the form of the bronchial tubes. These tubes are 
a series of gradually diminishing cylinders, and if a plug of any kind, 
but especially one closely adapted to the shape of the cylinders, and 
possessing considerable tenacity, be lodged in any portion of such a 
cylinder, it will move with much more difficulty towards the smaller 
end, and in doing so will close up the tapering tube much more tightly 
against the passage of air, than when moved in the opposite direction 
into a wider space. From this arrangement of the parts, it will hap- 
pen that at every expiration a portion of air will be expelled, which, 
in inspiration, is not restored, owing in part to the comparative weak- 
ness of the inspiratory force, and in part to the valvular action of the 
plug. "If cough supervene, the plug maybe entirely dislodged from 
its position, or expectorated, the air. of course, returning freely into 
the obstructed part; but if the expiratory force is only sufficient slightly 
to displace the plug, so as to allow of the outward passage of air, the 
inspiration will again bring it back to its former position, and the repe- 
tition of this process must, after a time, end in perfect collapse of the 
portion of lung usually fed with air by the obstructed bronchus." 

We have been thus particular in our consideration of the causes of 
collapse, because we are convinced, from personal observation, that it 
is a subject of very great importance in practice. Many times, in the 
last few years, we have met with cases of bronchitis, either primary or 
secondary, in weak and debilitated children, in which the general and 
local symptoms have pointed clearly to the existence of collapse of 
the lung, and in which, moreover, the good effects of a sustaining and 
even stimulating treatment have shown the great utility of an acquaint- 
ance with the nature of this affection, and its proper remedies. 

Symptoms. — As collapse of the lung occurs almost always in connec- 
tion with bronchitis, though sometimes, also, after, or concomitantly 
with pneumonia, it is clear that the symptoms which reveal its exist- 
ence must be mingled, in a greater or less degree, with those of the 



152 COLLAPSE OF THE LUNG. 

two diseases jast named. It is true, nevertheless, that it sometimes 
occurs unassociated with more than very slight evidences of any other 
disease of the lung. Cases of the latter kind have been usually ob- 
served only in children dying in states of utter exhaustion, in whom 
the muscular power of respiration has been so greatly weakened, as to 
prevent a dilatation of the thoracic cavity sufficient to carry air into 
the deeper parts of the lung. In such instances, the symptoms of col- 
lapse do not show themselves until a very short time before death, and 
they consist in the sudden appearance of very rapid and oppressed 
breathing, with little or no cough, in more or less extensive dulness 
on percussion over different parts of the chest, but most frequently the 
inferior dorsal regions, and in feeble or suppressed respiratory murmur, 
or more frequently a distant and imperfect bronchial respiration. In 
some cases, how^ever, in w^hich there is very little bronchial complication, 
as shown by the rarity and small amount of the catarrhal ral^s, the 
symptoms of collapse continue with more or less irregularity, as to 
situation and extent, for periods of several weeks, or even months. 
But here, also, as in the cases previously referred to, the general de- 
bility and low health of the child are strongly marked, and are, with 
slight variations, persistent. As an instance of this kind of collapse, 
we may cite the following case, which occurred in the j^ractice of one 
of ourselves : 

A boy, between three and four months old, who, at birth, and up to 
the time of this attack, had presented every appearance of strong and 
vigorous health, w^as seized, on the 3d of October, 1849, with symptoms 
of a somewhat irregular and anomalous character, but which we soon 
suspected to be the signs of an intermittent fever. We were induced 
in part to make this diagnosis, from the fact of having attended the 
mother during her gestation of this child, in a severe attack of inter- 
mittent fever. At the beginning of the sickness, there was some little 
corj^za, but no cough whatever. On the 3d of October, after the 
coryza had lasted for a few^ days, he became worse, and we were sent 
for. During the six days following this, he had one or two attacks 
each day of coldness of the extremities, followed by violent fever, and 
ending sometimes with perspiration. He w^as exceedingly fretful, 
screamed a great deal, was at times drowsy and dull, and vomited occa- 
sionally. The stools were regular and perfectly natural. The breath- 
ing was rapid and short nearly all the time, but there was no cough 
whatever. On the seventh day, the respiration was 100 by the watch, 
and irregular. The child was pale, weak, drowsy, and entirely with- 
out cough. Percussion revealed nothing, and no rales could be heard. 
On the eighth day, the breathing was 96, and a slight, dry cough was 
heard two or three times. When roused up, the intelligence of the 
child seemed perfect. On the ninth day, the breathing was 63, and the 
pulse 120. There was rather more cough, though still very little, and 
there was a slight return of the coryza, of Avhich there had been none 
for several days before. Neither auscultation nor percussion revealed 
any decided change in the lungs. On the eleventh day, the paroxysms 



ILLUSTRATIVE CASE. 153 

of chilliness, followed by fever, were still noticeable, though there was 
no clearly marked periodicity in the returns. When without fever the 
breathing was 54; during the fever it was 67. Auscultation revealed 
nothing decided. Percussion showed dulness beneath the right clavicle. 
By the seventeenth day, the intermittent nature of the disorder was 
more decidedl}" marked, and under a few doses of quinine the symptoms 
had improved, so that the breathing fell to 30 during sleep. The cough 
was a little more frequent, though still very slight, and it was loose. 
The coryza, also, was more considerable, the nasal discharge being 
quite abundant. 

After this the case went on badly, owing, we think, in great meas- 
ure, to the circumstance of the quinine being abandoned in conse- 
quence of the opposition made by the parents to its administration, — 
an opposition which we allowed to influence us more than was proper. 
During !N"ovember and December, the child remained weak, pale, 
languid, and with uncertain apf)etite, sometimes refusing the breast 
for a whole day at a time. The quinine was suspended at first on 
account of the great improvement which had taken place in the symp- 
toms, and though resumed afterwards, was given in such small quan- 
tities, and for so short a time, for the reasons just mentioned, as to be 
of no service. In December the child was very ill. It looked badly, 
having a pale, waxy face, and a dull, languid expression, though with- 
out any want of intelligence; it emaciated moderately, and had occa- 
sional vomiting; the stools were natural. At this time also it took the 
mother's breast with some difficulty, and refused artificial food alto- 
gether. Occasionally during this month there was observed a slight 
blueness around the mouth, and also about the hands and feet. Late 
in the month it was attacked with thrush in a slight degree, which 
lasted several days. In the first week of January, finding that it was 
fast sinking from refusing the mother's breast and artificial food, a wet- 
nurse was procured, and for a few days it seemed to improve a little, 
but this did not last. It grew w^eaker and thinner, the thrush returned, 
it had now a good deal of loose cough, the abdomen became somewhat 
contracted and felt hard and doughy, and the breathing was very rapid, 
though not greatly oppressed. The child died at last on the 26th of 
January, having, for ten days before that event, looked wretchedl}^ 
languid and haggard, and having presented for three days before, 
slight diarrhoea, loose, frequent cough, entire lose of appetite, thrush, 
drowsiness, and, finally, coma. 

At the autopsy there were found some fibrinous exudation, and a few 
adhesions over the lower half of the left lung. The lower two-ihirds 
of the left and the lower half of the right lung were dark-colored, more 
dense than usual, not friable, and exhibited no granulations on a cut sur- 
face. These portions were in fact collapsed. The upper lobes were 
spongy, crepitant, and healthy, ^ot a tubercle was found. The fora- 
men ovale presented an oval-shaped opening, of the size of a goose-quill. 
The abdominal organs were healthy. 

When, as indeed most usually happens, collapse occurs in the course 



154 COLLAPSE OF THE LUNG. 

of bronchitis, it is associated of course with the symptoms of that dis- 
ease. The bronchitic symptoms have lasted in their usual form for 
several daj^s, having been marked by sonorous, sibilant, and subcrepi- 
tant rales, when suddenly, or in the space of a few hours, the breath- 
ing becomes much worse, the pulse rises in frequency but becomes 
small and feeble, and certain changes take place in the physical signs 
which are very important. The subcrepitant rale continues to be 
heard, but it is associated now with prolonged expiration, and a little 
later with bronchial respiration, which, however, is of a different kind 
from the bronchial respiration of pneumonia, being distant and smoth- 
ered, instead of near and metallic, as in that disease. The percussion 
becomes, at the same time, dull and obscure, but never, scarcely, to the 
same extent as in pneumonia. The general symptoms are those of ex- 
haustion, rather than of high reaction. The surface is pale or slightly 
bluish, the skin is either natural in temperature, slightly warmer than 
usual, or coolish, the strength is very much reduced, and the child 
appears more seriously ill, and particularly more oppressed than the 
amount of bronchitis present would seem to explain. 

As an example of collapse occurring in the course of bronchitis, we 
will give the following case. A girl between two and three months 
old, healthy when born and up to the time of this sickness, saving that 
she was rather paler and smaller than most robust infants, was seized 
with coryza and slight cough, and after a few days with the symptoms 
of a mild bronchitis. For two days there was frequent cough, some 
little fever, quick but not oppressed breathing, occasional sibilant and 
mucous rale, perfect ability to nurse, and very moderate restlessness or 
fretfulness. On the third day, without any apparent reason, the symp- 
toms became suddenly very alarming. The breathing became ex- 
tremely rapid and most violently oppressed, so that the movements of 
the chest at each respiration were heaving and laborious, the shoulders 
being lifted high at each respiration, the outer angles of the mouth 
drawn downwards, and the alse nasi widel}^ dilated. There were at 
the same time abundant subcrepitant, intermingled with dry rales over 
the dorsum of the chest. In this case, moreover, the symptom men- 
tioned by Dr. Eees was very well marked. The base of the chest was 
driven inwards at each inspiration, producing at that point an evident 
constriction, whilst the upper parts were lifted high in the effort to 
carry on the respiration. The cough was frequent and racking, and 
occurred in paroxysms. The child was still and quiet, pale, had a hag- 
gard and exhausted look, was unable to nurse at all, and its i&urface 
was cool and white, especially that of the extremities. These symp- 
toms continued with very little modification for twenty-four hours, 
when, under the use of brandy administered every hour in milk drawn 
from the mother, of the spirit of Mindererus and paregoric, perfect 
quiet, and the assiduous employment of mild revellents, they began to 
moderate, and at the end of another twenty-four hours the constric- 
tion at the base of the thorax during inspiration had disappeared, the 
breathing was easy and gentle, the extremities had become warm, the 



DIAGNOSIS. 155 

child nursed eagerly and abundantly, and, with the exception of a 
slight catarrh, which lasted a few days longer, it was well. 

Collapse depending on bronchitic inflammation, in debilitated chil- 
dren, may sometimes last a considerable length of time. In one case, 
indeed, that we saw a few years since, and of which an account was 
published (see Am. Journ. 3Ied. Sci. for January, 1852, p. 98), the symp- 
toms, owing probably to the fact that the bronchitis causing the col- 
lapse was an accompaniment of hooping-congh, continued with slight 
variations in degree for a period of about three months, after which the 
child entirely recovered. 

Diagnosis. — The 'diagnosis of collapse of the lung must always be 
more or less uncertain where it is of the lobular form, for the reason 
that the collapsed lobules being disseminated irregularly through the 
pulmonary tissue, afford no physical sign by which we can detect their 
condition. The presence of this form ought, however, to be suspected 
whenever, in a chronic disease, and especially in the course of a catar- 
rhal attack occurring in a feeble and debilitated child, the breathing 
becomes excessively quick and labored, the skin pale and coolish, when 
the base of the thorax presents a depression instead of an expansion 
during inspiration, and, especially, when these symptoms occur without 
there being a sufficiently severe and extensive bronchitis to explain 
their existence. 

In cases of collapse afl'ecting a considerable or the greater part of a 
lobe, the diagnosis, though still perhaps rather uncertain, is much more 
clear and positive than in the lobular form. In the latter form we are 
obliged to depend, indeed, almost exclusively upon the rational symp- 
toms, the physical signs being either very slight or entirely null. In 
collapse of considerable portions of the lung-tissue, we have, on the con- 
trary, som6 very useful physical signs. These are, the existence of dul- 
ness, greater or less, on percussion; feeble respiratory murmur; pro- 
longed expiratory sound, and sometimes bronchial respiration ; which, 
when they occur in connection with, and in the course of bronchitis, 
are usually quite sufficient to render the diagnosis easy. 

The only diseases with which collapse of the lung, presenting the 
physical signs just mentioned, could be confounded, are pneumonia and 
pleurisy. From both of these it is usually distinguishable by the ab- 
sence in collapse, or the slight severity, of the reaetional symptoms, by 
the paleness or blueness and coolness of the surface, by the absence of 
acute pain, by the greater severity in collapse of the bronchitic symp- 
toms, and by the fact that it rarely occurs except in enfeebled, broken- 
down subjects, or in those laboring under severe bronchitis. The char- 
acter of the physical signs, moreover, is different. Though we have 
dulness on percussion in collapse, it is not so absolute as that either of 
pleurisy with large effusion, or that of confirmed pneumonia. The 
bronchial respiration, too, is in collapse different from that of pneu- 
monia. It is muffled and distant, instead of being clear, metallic, and 
close under the ear, as in pneumonia: and is heard, too, much more in 
the exj^iration than in inspiration. In collapse there is also heard, un- 



156 COLLAPSE OF THE LUNG. 

like either pneumonia or pleurisy, an abundant subcrepitant rale. To 
add to these differences, it is proper to say that, in cases of pneumonia 
and pleurisy, the course of the disease is much more regular, and the 
special symptoms so well marked as to leave no doubt as to the real 
nature of the attack. 

Prognosis. — The prognosis of collapse must depend, in great measure, 
on two circumstances — the amount of bronchitis which accompanies it, 
and the constitutional state of the child. When it occurs during the 
course of extensive bronchitis, as shown by a great abundance and ex- 
tent of the bronchitic rales^ it must add greatly to the danger of that 
disease; and if, at the same time, the child be weak and debilitated, 
either from causes long previously in action, or from the severity of the 
present attack, the risk to life is very great indeed. Collapse is dan- 
gerous, also, but far from necessarily fatal, in subjects in whom its chief 
cause has been simple debility. The possibility and the probability of 
recovery will depend on the hygienic conditions to which the child is 
exposed, the degree of vital strength it is likely to inherit from its 
parents, the extent of the collapse, as indicated by the severity of the 
thoracic symptoms^ both rational and physical, and the effects of treat- 
ment. When the subject can be placed under favorable hygienic con- 
ditions, when it has inherited from its parents a good and vigorous 
hold on life, and when the symptoms of collapse are not very violent, 
a proper and rational treatment w411 in all probability save it, w^hile, 
under opj)osite circumstances, the chance of recovery would be very 
small, if there were any. 

Treatment. — The treatment of collapse, or post-natal atelectasis, 
must vary somewhat in different cases. One general rule will apply, 
however, to all; that is, to employ a sustaining and strengthening sys- 
tem of medication, to the exclusion of all exhausting means. 

In cases which are entirely, or almost entirely, independent of bron- 
chitis, the most important measures to be attended to are the regula- 
tion of the temperature in which the child is kept, of the clothing, and 
of the diet, the use of mild stimulants and of tonics, and the external 
employment of revellents. The child ought to be kept in a warm, even 
temperature of from 70^ to 75°; it should be clothed in soft flannels, 
and its diet ought to be nourishing and strengthening. If at the breast, 
Ave should be sure that the milk is of a good quality, and that the nurse 
has an abundant flow. If weaned recentlj^, it ought to have, if possi- 
ble, a wet-nurse, and so also if it be supposed that the mother has too 
little milk, or that this is not perfectly healthy. If permanently weaned, 
the diet should be so arranged as to give to the child what is at the 
same time easy of digestion and nutritious. In a severe case, coming 
on suddenly, the most suitable internal remedies are brandy, in small 
doses, frequently repeated, Huxham's tincture of bark, the spiritus 
Mindereri or the aromatic spirit of hartshorn, and small doses of qui- 
nine or extract of cinchona. In slower and more chronic cases, we must 
depend on a well-selected and nutritious diet (and food ought to be 
given almost by force, or at least it should be urged strongly on the 



TREATMENT. 157 

child), on warm clothing, and on the use internally of brandy, quinine, 
the citrate of iron and quinine, pure metallic iron, the iodide of iron, 
Huxham's tincture of bark, or some such remedy. In sudden cases, 
the best revellents are the following: mustard weakened by admixture 
of flour or Indian nieal, and applied once in three or four hours; a 
plaster made of suet or simple cerate grated over with nutmeg ; or lini- 
ments composed of ammonia, spirit of turpentine, or oil of amber, mixed 
with sweet oil. In chronic cases, the Burgundy pitch, or compound 
Galbanum plaster, made somewhat weaker than those used for adults, 
should be applied over the front and back of the chest, or we may rub 
the thorax twice a day with any ordinary ammonia liniment, made, if 
necessary, rather more irritating than usual by the addition of some 
oil of monarda. The dail}' use of a gentle emetic of ipecacuanha has 
been recommended, and supposed to prove useful, by emptying the 
bronchia of their secretions, and also by the fact that its operation in- 
duces several deep inspirations, and in that mode promotes the better 
performance of the respiratory act. We have never employed the emetic 
except in cases accompanied with a good deal of bronchitis and con- 
sequent accumulation of mucus in the air-tubes, and not then when the 
prostration was very great. In fact, the operation of any emetic is 
sometimes productive of so much exhaustion of the strength, as to 
cause us to hesitate in prescribing a remedy of that class; though we 
can fully understand that the act of vomiting, if not followed by too 
much prostration, could scarcely fail to prove beneficial in collapse, by 
the strong efforts at breathing which it gives rise to, and also by the 
succussions it must imj)art to the lungs through the medium of the 
diaphragm. 

In cases of collapse occurring in the course of, or towards the termina- 
tion of severe bronchitis, the treatment must resemble a good deal that 
which we have just described as proper for the same condition, when it 
exists unassociated, or associated only to a slight extent, with that dis- 
ease. When the symptoms of imperfect expansion appear towards the 
termination of, or after the patient has partially recovered from bron- 
chitis, and when of course the strength is more or less reduced bj^ the 
severity of the previous acute sickness, and also perhaps by the neces- 
sary measures of treatment, the case ought to be managed very much 
in the same way as has just been recommended for those in which the 
collapse was caused chiefly by exhaustion, and less by the presence of 
obstructing secretions in the bronchia. Nourishing, but very light and 
digestible food ; mild stimulants, as small quantities of brand}^ or wine- 
whey; the bitter tinctures, iron, or quinine, with counter-irritants to 
the surface of the chest, warm clothing, and repose, constitute the 
necessary and most reasonable remedies. When, on the contrary, the 
atelectasial condition supervenes in the midst of extensive and severe 
bronchitis, we are called upon to treat at the same moment two morbid 
states, one consisting of active inflammation, and another of want of 
power in the muscles of respiration to force the atmospheric air through 
the secretions which are obstructing the air-passages. Under these 



158 COLLAPSE OF THE LUNG. 

circumstances, there is almost always associated with the bronchitis, as 
we shall find when we come to treat of that disease, more or less intense 
congestion of the collapsed portions of the lungs. We must employ, 
therefore, such remedies as tend to modify tlie inflammation of the 
bronchial mucous membrane, and diminish thereby the amount of secre- 
tion poured into the air-passages ; such as may serve to expel mechani- 
cally those secretions; and those which shall unload the congested 
lung of its excess of blood, always taking care, in our selection of the 
agents to accomplish these ends, to choose those which are the least 
perturbative and exhausting. To moderate the inflammation of the 
bronchial mucous membrane, and with a view also to unload the con- 
gested parts of the lung, w^e may apply a few dry cups, or rely on 
counter-irritation, the best mode of effecting which is by the repeated 
application of mustard poultices, consisting of one-third mustard to 
two-thirds Indian meal or flour, and by mustard foot-baths. These 
poultices ought to be applied first to the dorsum and then to the 
front of the chest, once in every three or four hours, and they should 
be made large enough to cover a considerable portion of the thoracic 
walls. Counter-irritation, assiduously made use of, is, we believe, one 
of the most, if not the most effectual means of treatment in the case. 
Emetics ought to be given twice a day, or even three times, if they do 
not reduce the strength too much. The best are those which operate 
wdth the least subsequent prostration^ such as ijDccacuanha or alum. 
When they are found to exhaust much, and to increase thereby the 
labor of breathing, their use must be suspended. 

After emetics, or when these cannot be used, the remedies from 
which we have obtained the greatest benefit are the liq. ammon. acetat., 
and seneka, either in decoction or syrup, combined sometimes with 
small quantities of opium. To a child two years old we should give 
twenty drops of the acetate of ammonia solution, with ten of the syrup 
of seneka, or with a teaspoonful of decoction of seneka, every two hours. 
When the cough is paroxysmal, painful, and harassing, about ten drops 
of paregoric, half a drop or a drop of laudanum, or from four to six 
drops of solution of morphia, may be added to each of the above doses. 
The opiate ought to be continued until the cough and restlessness 
diminish, and then be suspended. In all these cases, there should be no 
hesitation in giving small quantities of brandy or wine-whey, whenever 
the symptoms of prostration are so marked as to indicate danger; and 
these stimuli are urgently called for when the pulse is very rapid and 
small, when the skin is cool or pale and bluish, and when the general 
aspect of the patient, and the convulsive and labored character of the 
breathing, show that the muscular strength of the child is scarcely suf- 
ficient to carry on the function of respiration. 



PNEUMONIA. 159 

AETICLE II. 

PNEUMONIA. 

Definition; Synonyms; Frequency; Forms. — The term pneumoDia 
is now, by universal consent, applied only to inflammation of the par- 
enchymatous structure of the lungs. It is often called, in this coun- 
try, catarrh-fever, lung-fever, or inflammation of the lungs. 

It is one of the most frequent, and, therefore, one of the most im- 
portant of the acute diseases of childhood. Dr. West, in a j)aper on 
the pneumonia of children (Brit, and For. j\Jed. Rev., April, 1843), in- 
forms us that the English tables of mortality show pneumonia to be 
the cause of a larger number of deaths in childhood than any other dis- 
ease, with the exception of the exanthemata. From the third report 
of the Registrar-General, he quotes the facts that of all the deaths in 
the metropolitan districts under fifteen ^^ears of age, 13.6 per cent, were 
from pneumonia, 13.0 per cent, from convulsions, and 5.4 per cent, 
from hj'drocephalus. He obtained nearly similar results from an ex- 
amination of the returns from Manchester^ Liverpool, and Birming- 
ham. 

In this city it appears from the bills of mortality that the deaths 
from this disease are strikingly below the percentage calculated by 
Dr. West. Thus, during the seven years ending with 1869, the total 
mortality from all causes (excluding still-born children) was, at all ages, 
105,785; under fifteen years of age, 50,151; and under five years, 43,322. 
The total mortality from pneumonia during the same period was, at 
all ages, 5567, or 5.26 per cent, of the entire mortality; under fifteen 
years, 2985, or 5.95 per cent, of the mortality under that age; and under 
five 3'ears, 2746, or 6.33 per cent, of the mortality under that age. 
During the same series of years, the total mortality from bronchitis 
was, at all ages, 969, or less than 1 per cent, of the entire mortality ; 
under the age of fifteen years, 509, or 1.01 per cent, of the mortality 
under that age; and under the age of five years, 495, or 1.14 per cent, 
of the mortality during the first five years of life. 

Any one who will study with attention the various doctrines in re- 
gard to pneumonia and bronchitis that have been set forth in the dif- 
ferent works on the diseases of children, will most assuredly acknowl- 
edge that there are few diseases about which there has prevailed so 
much diversity of opinion as to the real nature of the lesions forming 
the essential anatomical characters of the disorder, and, as a conse- 
quence of this, so much doubt as to the proper mode of classifying and 
describing them. From the time of the appearance of the works of M. 
Yalleix, M. Barrier, Dr. Gerhard, and especially that of MM. Rilliet 
and Barthez, up to the moment of publication of the essay of MM. Le- 
gendre and Bailly (referred to in the article on atelectasis), it was com- 
monly believed that inflammation of the parenchyma of the lung ex- 



160 PNEUMONIA. 

hibited in children very different characters in the majority of the 
cases, from those which marked the pneumonia of the adult. Two 
principal forms of the disease were therefore described by most writers, 
— the lobular and the lobar. The former was supposed to be almost 
peculiar to children, and to occur only on rare occasions in adults; the 
latter was held to resemble, in almost everj- respect, the pulmonic in- 
flammation of the adult. Moreover, lobular pneumonia was generally 
believed to be by far the most common form assumed by the inflam- 
mation in children under five years of age, whilst lobar pneumonia was 
thought to be comparatively rare under the age mentioned. Besides 
these two chief varieties of pneumonia, two others have been described 
under the names of vesicular and marginal pneumonia, while to yet 
another MM. Eilliet and Barthez applied the title of carnification. 

The researches of MM. Legendre and Bailly have caused a great 
revolution in the views of a large number of medical observers and 
writers. These authors first pointed out (as stated in the article on 
atelectasis) that a very large proportion of the cases previously de- 
scribed under the titles of lobular pneumonia, generalized lobular pneu- 
monia, pseudo-lobar pneumonia, marginal pneumonia, and the carnifi- 
cation of MM. Eilliet and Barthez, were in fact cases of bronchitis 
variously associated with congestion and collapse of the tissue of the 
lung. They themselves described these supposed different forms of 
pneumonia under the title of catarrhal pneumonia. But, though they 
were opposed to the opinion of lobular pneumonia being a true inflam- 
mation of the lung, they did not assert that children were not subject, 
like adults, to regular inflammation of the pulmonary parenchyma. 
They described, in fact, as nearly all others have done, a lobar pneu- 
monia, which exhibits the same anatomical characters, and very nearly 
the same train of symptoms, both rational and physical, as the pneu- 
monia of adult life; and a iKirtial pneumonia, in which the inflamma- 
tion, instead of invading a large part of a lobe or a whole lobe, attacks 
isolated small portions of the parenchyma, so as to present an appear- 
ance of nodules of inflammation scattered here and there through the 
healthy tissue. 

Since the publication, in 1844, of the views arrived at by MM. Le- 
gendre and Bailly, numerous other observers have repeated and con- 
tinued their researches, but with very different results. Some have 
adopted their opinions entirely, others in part, while a few still adhere 
tenaciously to the old doctrines. Amongst those who now believe that 
lobular pneumonia in its different forms is in fact bronchitis with col- 
lapse of the lung-tissue, and not inflammation of the pulmonary paren- 
chyma, the most important are Drs. West and W. T. Gairdner (loc. cit.\ 
MM. Hardy and Behier {Pathol Int., t. ii, p. 529, et seq.), MM. Eilliet 
and Barthez, in their second edition, and Dr. Fuchs {Brit, and For. 
Med.-Chirurg. Bev., July, 1850, p. 154, et seep). Amongst those who op- 
pose the new views, we may mention the names of M. Bouchut and 
those of the authors of the Compendium de Medecine Pratique. We 
would refer any one who desires to study this matter as treated by 



FORMS — PREDISPOSING CAUSES. 161 

English hands to the essay On the Pathological Anatomy of Bronchitis 
and the Diseases of the Lung connected with Bronchial Obstruction, by Dr. 
AY. T. Gairdner, of Edinburgh. It is decidedly the best Englisli work 
on the subject we have seen, for it treats not only of atelectasis in chil- 
dren, but contains yet more numerous observations upon the same con- 
dition as it occurs in adults. The second edition of MM. Eilliet and 
Barthez is also very full on this subject, those authors adopting in great 
measure, as above stated, the views of MM. Legendre and Bailly. 

Our own opportunities for investigating this interesting subject by 
post-mortem examination have been comparatively few, so that we have 
been obliged to form our conclusions in regard to it chiefly from a study 
of the researches of others, and from a comparison of the symptoms 
which we have observed during life in the different pulmonary aflPec- 
tions of children, with those researches and with the results we have 
obtained from the few autopsies that we have been able to make. As- 
sisted b}' these combined means of forming a conclusion upon the sub- 
ject, we have been led to the belief that the former method of dividing 
the pneumonia of children into the two forms of lobular and lobar is 
incorrect, and we have determined to substitute for the term lobular 
that oi partial, which is the one employed b^^ M. Legendre and also by 
Dr. Alois Bednar {Die Krankheiten der Neugebornen und Sduglinge, Dritter 
Theil, Wien, 1852, p. 65), while we shall describe the other form of the 
disease under its usual title of lobar. Of these two forms, the latter is 
much the most frequent, though it was formerly thought that the lobu- 
lar was more common than the lobar variety, simply from the fact that 
bronchitis attended with lobular collapse (the condition heretofore 
almost always described as lobular pneumonia) is much oftener met 
with in children than true pneumonia, either lobar or partial. 

Predisposing Causes. — It is generally believed that pneumonia is 
most apt to occur in the course of other affections. This is certainly 
true in regard to the disease as it prevails in hospitals, and probably 
amongst the poorer classes of society also. MM. Eilliet and Barthez 
state that of two hundred and forty-five cases observed by themselves, 
only fifty-eight, or a little less than a fourth, occurred in children pre- 
viously in good health. The proportion of secondary cases is much 
smaller in private practice, since of fifty-one cases of well-marked pneu- 
monia, observed by ourselves, in which this point was noted, onlj'" six 
were secondary. JN'o doubt one cause of this apparent discrepancy 
between the authors mentioned above and ourselves, is the fact that 
we have left out of consideration all the cases in which the pneumonic 
symptoms were not entirel}" clear, thus putting aside a number of cases 
which they would have classed as lobular pneumonia, but which we 
prefer to regard as examples of bronchitis with collapse. Age forms a 
strong predisposing influence. Of the two hundred and forty-five eases 
above quoted, one hundred and seventy-two occurred under five years 
of age. Dr. West (loc. cit.) says that during the first five years of life, 
the cases of pneumonia were in the proportion of 10.3 per cent, to the 
total of diseases^ while in the succeeding five years they were in the 

11 



162 



PNEUMONIA 



proportion only of 1.3 per cent. The mortality bills of this city exhibit 
the same marked excess in the proportion of deaths from pneumonia 
under five 3'ears of age, as compared with the ensuino; years. We have 
already seen tiiat the proportion during the first five years of life is 
6.33 per cent, of the entire mortality under that age; while during the 
ensuing ten years the deaths from pneumonia form but 3J per cerjt. of 
the total mortality during that ]jeriod of life. These statements do not 
agree with our own experience in private practice, since of fifty-five 
cases that we have seen in which this point was noted, twenty-eight 
occurred under five, and twenty-six between five and eleven years of 
age, showing that the frequency in the fii*st five and the subsequent six 
3^ears of life is very nearly the same. True pneumonia is less frequent 
in private practice in the first two, than in the succeeding years of life. 

Sex. — A larger number of cases occur in boys than girls. The excess 
is probably not more, however, than may be accounted for by the pre- 
pondei-ance of male over female children. Of fiftj^-five cases in which 
we have noted the sex, thirt}' occurred in boj's, and twenty-five in girls. 

Constitution. — It is doubtful w^iether constitution has much or any 
influence upon the liability to the disease. Dr. West says that weak 
health is not a predisposing cause, according to his experience. We 
are convinced that it attacks strong and vigorous children more fre- 
quently than those of more delicate constitution. In children of feeble 
health and weak stamina, the very same causes w^hich produce pneu- 
monia in the robust, give rise to bronchitis. 

Season. — The disease is most prevalent during the winter and early 
spring months, as will be seen from the accompanying table, in which 
is shown the mean monthly mortality in Philadelphia, for the seven 
years ending 1870, from this disease, as well as from bronchitis. From 
this it will be seen that in December, January, F'ebruary, and March 
(and the same is very nearly true of April also), the deaths from these 
diseases are three times as numerous as in August. 



Months. 

January, . 
February, 
March, . 
April, . 
May, . . 
June, . . 
July, . . 
August, 



Mean monthly 
mortality for 7 years, 
from Pneumonia 
and Bronchitis. 


Mean total 
mortality from all 
causes (includ- 
ing still-born) 
for 7 years. 


Mean monthly* 
percentage for 

7 years, from 
Pneumonia and 

Bronchitis. 


Mean monthly 

temperature 

(F.) for 7 years. 


Pneumonia, 
Bronchitis, 


. 46 
. 6.29 


1296.71 


3.54 
0.48 


30.87° 


Pneumonia, 
Bronchitis, 


. 45.57 
. 8.43 


1206.71 


8.76 
0.69 


33.89° 


Pneumonia, 
Bronchitis, 


. 48.57 
. 7.14 


1344.29 


3.61 
0.53 


40.85° 


Pneumonia, 
Bronchitis, 


. 41.57 
. 571 


1281.14 


3.24 
0.44 


52.27° 


Pneumonia, 
Bronchitis, 


. 34.76 

. 6.57 


1234.29 


2.81 
0.53 


62.77° 


Pneumonia, 
Bronchitis, 


. 26.14 
. 5.00 


1178 14 


221 
042 


71.97° 


Pneumonia, 
Bronchitis, 


. 24 14 
. 4.00 


1837.00 


131 
0.21 


77.71° 


Pneumonia, 
Bronchitis, 


. 20.14 
. 3.00 


1825.43 


1.10 
0.16 


76.62° 



INFLUENCE OF SEASON — ANATOMICAL LESIONS. 



163 



Months. 

September, 
October, . 
IS'ovember, 
December, 



Mean monthlr 
mortality for 7 years, 
from Pneumonia 
and Bronchitis. 


Mean total 
mortality from all 
causes (includ- 
ing still-born) 
for 7 years. 


Mean monthly 
percentage for 7 

years, from 

Pneumonia and 

Bronchitis. 


Mean monthly 
temperature 
(F.) for 7 years. 


Pneumonia, 
Bronchitis, 


. 14.57 
. 5. -29 


1215.43 


1.19 
0.43 


68.31° 


Pneumonia, 
Bronchitis, 


. 22.43 
. 5.43 


1218.14 


1.84 
044 


56.30° 


Pneumonia, 
Bronchitis, 


. 28.86 
. 5.71 


1052.14 


2.74 
54 


46.68° 


Pneumonia, 
Bronchitis, 


. 39.57 
. 8.14 


1191.00 


3 32 
0.58 


34.74° 



We have also placed in parallel columns the mean percentage of mor- 
tality fi'om these two diseases, and the mean monthly temperatures, in 
order to show the marked correspondence between the coldness of the 
weather and the frequency of pneumonia and bronchitis. It is evident, 
however, that there is another element, beside the mere temperature, 
in determining their frequenej^, since, in both February and March, 
more deaths occurred from these causes than in January, although this 
latter is the coldest month of the year. The additional element is un- 
doubtedly' to be found partly in the sudden atmospheric changes, and 
damp, raw days which are so frequent, in both February and March, 
in our latitude, and partly in the impaired vitality found in many chil- 
dren, as the result of the intense cold of the preceding months. 

Previous Diseases. — It is apt to occur as a complication of all the dis- 
eases of children, and most frequently in measles, pertussis, typhoid 
fever, enteritis, and bilious remittent fever. 

Exciting Causes. — The continued action of some of the predisposing 
causes must be regarded as the exciting cause in the majority of the 
cases. External violence, as a severe fall, or a blow upon the chest, 
will sometimes act as an exciting cause. The action of cold is almost 
always alleged to be the immediate cause of the attack. M. Grisolle 
states that it is impossible to determine the exciting cause in more than 
a fourth of fhe cases, and that in nearly all of these it is cold. 

Anatomical Lesions. — Lobar pneumonia in the child is marked by 
the same physical characters as in the adult. The three stages of the 
inflammation — engorgement, red hepatization, and gray hepatization — 
exhibit the same alterations of the tissues as in adult life. Moreover, 
the three stages occur with about the same frequency in early as in 
later life. Dr. West (loc. cit., 2d ed., p. 189) shows that the third stage 
occurs very nearly as often in children as in adults, he having met with 
it in the former in the proportion of sixty-eight per cent., while M. Gri- 
solle found it in seventy-two per cent, of the latter. The chief differ- 
ence in the disease, as it exists at the two ages, consists in the more 
frequent coexistence of all three of the stages in the young subject. 

In the first stage, or that of engorgement, the affected portion of 
lung is distended, so that it does not collapse in the saiue proportion as 
the healthy portions, when the thorax is opened. It is heavier than 
usual, so that it sinks somewhat in water: it is of a brownish-red color; 



164 PNEUMONIA. 

it pits upon pressure, and crepitates less than healthy lung, the crepi- 
tation being observable only here and there. The natural degree of 
cohesion between the tissues is somewhat diminished, so that the dis- 
eased portion is much less tough and elastic, and more soft and friable 
than it ought to be. When cut into, a large quantity of frothy, and 
more or less deeply-tinged sanguineous fluid escapes. 

In the second stage, or that of red hepatization, the lung is increased 
in volume, so that it continues to fill the side of the chest after that 
cavity is opened; it is dense and hard, has ceased entirely to crepitate, 
from the fact of having become completely impermeable to air, and 
sinks rapidly when thrown into water. Externally, the diseased por- 
tion is of a deep-red color, while internally the same color is observed, 
but often of such different shades as to give to a cut surface a marbled 
aspect. The cohesion between the tissues is, in this stage, much less 
strong than in health or in the first stage of the disease; the finger 
penetrates the lung with some ease, and the texture can be crushed be- 
tween the finger and thumb. When cut into, there escapes a non- 
aerated and reddish fluid, which is much less abundant than in the first 
stage. The most important feature of red hepatization is, however, the 
granular character of an incised surface. This granular appearance is 
produced by the presence of numerous minute flat granular elevations, 
which are the air-vesicles distended with the plastic lymph which has 
been exuded within them. It is best seen by examining a torn surface 
of the lung. 

In the third stage, or that of gray hepatization, the lung continues 
to exhibit the same volume, density, impermeability to air, and conse- 
quent total absence of crepitation, as in the second; but the process 
of softening has made still further progress, so that a portion of the 
lung may be squeezed with the greatest ease between the finger and 
thumb into a pulp. The color has now changed from deep-red to a 
dirty light-gray, or a pale straw-yellow. When incised, the surface 
still presents a granular appearance, but the granules are more irregu- 
lar and flatter. The diseased portions are now infiltrated \vith a puru- 
loid fluid, which escapes in considerable quantities in the form of a 
yellowish-gray liquid, whenever the lung is cut into. 

The anatomical lesions, which characterize partial pneumonia^ occur 
under two conditions. In one the alterations are exactly the same as 
those of the lobar form, the only difl'erence between the two being that, 
in the partial form, the hepatization affects distinct patches of the pul- 
monary substance, producing, therefore, hard nodules of hepatization 
scattered through healthy tissue. These nodules are irregular in form, 
and imperfectly circumscribed, but present, like the lobar form, the 
three stages of the inflammation — engorgement, red hepatization, and 
gray hepatization. The second variety of partial pneumonia is charac- 
terized by patches of hepatization, varj^ing in number from fifteen to 
thirty, and in size from that of a hemp-seed to that of a pigeon's agg, 
which are more or less spherical in shape, hard to the touch, and ex- 
actly limited. M. Legendre states that these hepatized points become 



ANATOMICAL LESIONS. 165 

transformed into a grayish, rough, and uneven substance, of a fibrous 
appearance; a change -vvhich takes place at different points of the dis- 
eased mass, sometimes in the centre only, sometimes in their whole ex- 
tent, and at others on their circumference. 

Abscesses are not very uncommon in the pneumonia of children. 
They occur as a result of the third stage of the disease, so that in the 
same lung may be observed the first, second, and third stages of the 
inflammation, and abscesses. The cavities of the abscesses are gener- 
ally circular, sometimes oval, and they measure from half a line to an 
inch or more in diameter. Sometimes the abscess is multilocular, each 
of the purulent cavities being partially separated from its neighbor by 
a wall of hepatized tissue. They are found in various parts of the lung, 
but seem disposed, generally, to approach the surface of the organ. 
When the latter event happens, adhesive inflammation between the 
pulmonary and costal pleura usually takes place; but should this fail to 
occur, the abscess may rupture into the pleural sac, and produce pneu- 
mothorax. MM. Eilliet and Barthez met with two examples in their 
autopsies in which this accident had occurred, and they report another 
case in which it occurred during life, and in which the child recovered. 
We have met with three cases of pneumothorax ourselves, produced in 
the same way. One occurred in a boy eleven years old, during an at- 
tack of secondary pneumonia complicating a severe bilious remittent 
fever. The patient recovered entirely after a most violent illness. The 
two others occurred in ver}^ young children, and proved fatal. 

We are desirous, before closing our remarks on the anatomical 
lesions of the disease under consideration, of drawing attention to the 
subject of simple non-inflammatory congestion of the lung, for the 
reason that the latter has no doubt, especially when associated with col- 
lapse of the pulmonary tissue, been frequently mistaken for pneumonia. 

Congestion of the lung occurs either in the lobular or lobar form, the 
distinction between the two being the same as that between lobular 
and diffused or lobar collapse. When lobular, the lung presents, gen- 
erally along the posterior edge of the organ, disseminated lobules, 
distinctly circumscribed by the interlobular cellular septa, which are 
rather protuberant than depressed, more friable, and of a lighter 
purple color than collapsed lobules, and which aflbrd, when squeezed, 
a considerable quantity of frothless bloody fluid. In very young in- 
fants, the congestive disposition often assumes the lobar or diffused 
form, and is supposed by M. Legendre to have frequently been taken 
for pneumonia. In this variety of congestion, the afl'ected portion of 
the lung is increased in size, and is distended and gorged with fluids. 
The color of the congested part varies from a light to a dark purple, 
or almost blackish tint. The cohesion of the lung is also variable, the 
differences depending on the degree of the congestion. When this 
latter is very great, the part is very friable, while it is much less so 
under the opposite condition of things. Though the lung is harder in 
this state than natural, it still retains a certain degree of flaccidity 
which does not exist in true hepatization. Pressure causes an abun- 



166 PNEUMONIA. 

dant exudation of blood and serosity from a cut surface, and the latter, 
instead of being granulated, as is always the case in hepatization, is 
smooth and even. Neither does the lung exhibit any granulations 
when it is torn. Lastly, inflation distends all the vesicles, and gives 
to the condensed parts their natural lightness and their rosy color, 
though, be it remarked, the development of the affected parts under 
the operation is not complete and entire, as in collapse, in consequence, 
no doubt, of the large amount of blood they contain. 

Inflation of the lung after death has been much employed of late, as 
any one who has read the previous remarks on atelectasis must have 
seen, as a means of distinguishing between pneumonia and collapse. 
It was there stated that, whilst inflation distended, and restored more 
or less completely to their natural condition, parts of the lung that 
were merely collapsed^ it failed almost entirelj' to have any effect on 
parts of the lung affected with true pneumonia. It is easy to under- 
stand wh}' inflation should fail to exert much effect on inflamed lung, 
at least when the disease has reached the state of hepatization. In 
fact, the tissues comprising the lung are glued together and hardened 
by a deposit of plastic lymph, poured out chiefly on the inside of the 
air-cells, so that it becomes impossible to force the air into the midst 
of the agglutinated structures. In the first stage of j^neumonia, that 
of congestion, inflation will distend in some degree the affected portions, 
but, in the second and third stages, not even the strongest force has 
any effect on the impermeable vesicles. 

Lobar pneumonia is stated by most authorities to be generally con- 
fined to one lung, and such has been our own experience in regard to 
it, since of 56 cases in which its location was carefully determined, it 
was unilateral in 52, and double only in 4. It is much more common 
on the right than left side, according to most writers. In the 52 cases 
just referred to, the distribution was nearly equal, the disease being 
seated 29 times on the right side, and 23 times on the left. It attacks 
the lower lobe much more frequentlj' than the upper, though pneu- 
monia of the upper lobe is much more frequently met with in children 
than in adults. Of 51 cases in which this point was determined, the 
upper lobe was the part affected in 20, while in 31 the base of the lung 
was the seat of the disease. Of the 20 cases of inflammation of the 
upper lobe, in 13 it was seated on the right, and in 7 on the left side. 
Of 31 cases occurring in the lower lobes, 15 were on the right, and 16 
on the left side. In the 1 cases of double pneumonia, the inflammation 
attacked the lower lobes of both lungs in one; in one the postero- 
inferior part of both upper lobes was especially involved; while in the 
two others it attacked first the base of the left lung, and afterwards 
the summit of the right. 

The statements just made as to the seat of the pneumonic inflamma- 
tion in the cases that have come under our own observation, do not, we 
are well aware, agree exactly with the experience of other observers. 
Dr. West, for instance, found {loc. cit., p. 190) that double pneumonias 
preponderated greatly, in early life, over those wherein only one lung 



ANATOMICAL LESIONS — COMPLICATIONS. 167 

suffered. This, it will be observed, is widelj' different from the result 
of our experience, and it is also directly opposed to that of MM. Killiet 
and Barthez, Eufz, and Barrier. M. Barrier, in fact, cites {Mai. O.e 
L'Enfance, t. i, p. 286) 1^1 cases of lobar pneumonia as having been 
observed by the authors just mentioned, and bj himself, and of these 
only 15 were double. Our results in regard to the frequency of double 
lobar pneumonia agree, therefore, with those of the authors last men- 
tioned, but they differ as to the relative frequency with which the two 
lungs are attacked. Thus, in our cases, the inflammation occurred with 
nearly equal frequency in the two lungs, whilst of 129 cases of unilateral 
pneumonia observed by the above authors, 84 were seated in the right, 
and -15 in the left lung. These writers state, as most others do, that pneu- 
monia of the lower lobe is more common than that of the upper lobe. 
This tallies with our observations, but, as it seems to be a general opin- 
ion in the profession, that inflammation of the summit of the lung is 
rare in comparison with that of the base, we wish to call attention 
again to the fact stated above, that of 51 cases, in which we ascertained 
accurately the seat of the disease, it w^as in the upper lobe in 20, and in 
the lower in 31. 

It was formerly supposed that bronchitis was an exceedingly frequent 
accompaniment of pneumonia, and there is no doubt that such is really 
the fact in a much larger proportion of the cases that occur in children, 
than of those that occur in adults. But, since the discovery of the 
nature of the anatomical alteration which we have described under 
the title of collapse or atelectasis, it has become clearly evident that 
one reason why it was thought that bronchitis so generally accompa- 
nied the pneumonia of children, has been that a large number of cases, 
heretofore classed as pneumonia, were in reality cases of bronchitis at- 
tended with collapse. It has been shown, indeed, in the preceding 
pages, that there is good reason to believe that a very large majority 
of the cases hitherto described as lobular pneumonia, ought to be classed 
under the head of bronchitis. J^ow, these cases are precisely those in 
which bronchitis has been found to occur so constantly, and to form so 
large a portion of ihe disease; and they, moreover, have always been 
stated to be of much greater frequency than cases of lobar pneumonia. 
If^ however, we conclude to regard what was formerly called lobular 
pneumonia, as bronchitis with collapse, and to restrict the title of pneu- 
monia to the cases in which there is a true hepatization of the lung, 
we shall have left only lobar pneumonia, which is not at all a rare affec- 
tion, and partial pneumonia. Now, in the lobar pneumonia of children, 
as in that of adults, bronchitis does not usually exist to any vory con- 
siderable extent, and we may state, therefore, that, though bronchitis 
exists to a greater or less extent in most of the pneumonic cases of 
children, it is in a much less severe degree than was at one time sup- 
posed. 

When bronchitis is present it varies from simple increased vascularity 
with augmented mucous secretion, to intense congestion with purulent 
or pseudo-membranous secretion. 



168 PNEUMONIA. 

Pleurisy is a frequent complication, as it is found to exist in about 
half the cases. 

JSmphysema is another common complication. It generally occupies 
the upper part of the lung, or its free edge, and is found most strongly 
developed in the lung which presents the greatest amount of inflamma- 
tion, or in both, when both are inflamed. Its degree depends on the 
extent of the pulmonary inflammation and bronchitis, and the severity 
of the dyspnoea. The vesicular form is much more frequent than the 
interlobular. 

Symptoms; Sketch of the Disease; Course. — In order to present a 
faithful account of the disease, a general sketch of the symptoms will 
first be given, after which the most important ones will be considered 
separately under the head of particular symptoms, so that the reader 
ma}^ first obtain a notion of the course of the disease, and then become 
intimate!}^ acquainted with its details and peculiarities by reference to 
the remarks on each particular symptom. 

True pneumonia, wnth well-marked hepatization, is not, according to 
our experience, a common affection in young infants in private practice, 
since out of fifty cases of the disease that we have met with in children, 
in which we have noted this point, only two occurred in infants within 
the first, and three in the second year. Of the two cases within the 
year, one occurred in a child six wrecks old, and the other in one seven 
months. 

In new-horn children, and those still at the breast, pneumonia very gen- 
erally begins with more or less marked symptoms of bronchitis, though 
in some instances it commences suddenlj^, as it does in adults, without 
any previous sign whatever of bronchial inflammation. When it occurs 
during an attack of bronchitis, the symptoms which belong to the pneu- 
monic inflammation will, of course^ have been preceded by those which 
depend on the disease of the bronchial mucous membrane. In these 
cases, the development of the pneumonia will be indicated by an aggra- 
vation of the general symptoms, by an increase of the oppression, by 
the fact that the cough and breathing both become more painful than 
before, and by the occurrence of the physical signs peculiar to pneu- 
monia, or, in other words, by the symptoms which depend upon and 
mark a state of inflammation of the parenchyma of the lung. Of these 
we shall now give an account. 

When pneumonia appears as a primary affection in young children, 
without preceding bronchitis, as sometimes undoubtedly happens, 
though much less frequently than in children over five years of age, 
and especially than in adults, the attack is usually sudden. The first 
symptoms observed are restlessness, peevishness, disposition to cry, a 
diminished appetite for the breast, and feverishness. These symptoms 
are most marked in the evening and night. From the very first, or by 
the second day at least, cough is heard, and careful examination of the 
breathing will show that it is somewhat hurried. The cough is dry, 
short, and hacking, at first, and not verj^ frequent, but it soon becomes 
louder, fuller, more straining, and especially it becomes painful. The 



SYMPTOMS. 169 

fact that it is painful may always be ascertained by watching the motions 
of the child, its cry, and the expression of the face. We can always 
perceive, even in an infant, a disposition to restrain the cough, to 
smother it, a struggle to make it short and sudden, when it causes 
sharp pain. At the moment of the cough, too, a marked expression of 
pain, a kind of sudden grimace or twisting of the features, may always 
be observed, which is accompanied or followed instantly by a loud, 
sharp cry, or a spell of crying. This grimace of pain, with the accom- 
panying cry, we have never observed in their most characteristic form 
in simple bronchitis, but only in pneumonia and pleurisy. We have 
twice seen these symptoms so decidedly marked that they could not 
fail to have drawn any one's attention ; once in an infant six wrecks old, 
who died of a most violent and extensive pleuro-pneumonia, and again 
in a child thirteen months old, who died of pleurisy resulting in the 
formation of pure pus in the pleural sac. The nature and extent of the 
lesions were ascertained, in both cases, by examination after death. 
The presence of pain in the side is shown also by the fact that full in- 
spirations, caused by changing the position of the child, and those which 
occur during fits of crying, occasion a sudden arrest or stoppage, so to 
speak, of the act of inhalation, which gives to the crying, and often 
also to the breathing, a sobbing character, while across the countenance 
passes at the same moment the expression of pain alreadj^ referred to. 
The breathing, which is only slightly disturbed at first, soon becomes 
frequent and attended with more or less efi'ort, and gives rise to an un- 
usual play of the nostrils, a symptom which ought always to attract 
attention to the respiratory system as the seat of disorder. It interferes 
also with the act of nursing, so that whether the child takes the breast 
less frcquentl}^ than usual, from want of appetite, or seeks it with 
greater avidity than common, from thirst, the act of sucking is attended 
with some difficulty. The infant seizes the breast for a few instants, 
then lets go in order to breathe more easily, and seizes it again ; or it 
drops the nipple suddenly and begins to cry, as though the act of suck- 
ing were painful from the necessity it begets of taking occasionally a 
fuller and deeper inspiration than usual. As a general rule, the bow^els 
are torpid, while vomiting, which is rather unusual in older children, is 
quite common in young infants. 

When the disease is once established, whether it have been preceded 
by bronchitic S3^mptoras, or occur as a primary affection, the symptoms 
are generally well marked, so as to leave but little difficulty in the 
recognition of the disorder. The child now loses all gayety and cheer- 
fulness, and becomes either dull and listless, or very restless, peevish, 
and troublesome. Young infants generally lie quietly on the bed, or in 
the lap, merely fretting and crying when they cough, or when they are 
moved for any purpose, while children of several months old, and those 
in the second year, are usually vcrj^ cross and restless, crying and 
screaming when anything is done for them, and insisting upon being 
frequently moved from the cradle or bed to the lap, or from the lap to 
the cradle. As a general rule they are contented only upon the lap, 



170 PNEUMONIA. 

always crj'ing to get back when they are removed from it to the cradle 
or crib. In some instances, however, they, like young infants, are quiet 
and dull, being content to lie still when placed in a comfortable posi- 
tion, and crying only after coughing, for the breast or drink, or when 
disturbed. 

A febrile reaction now displays itself in full force. The skin becomes 
hot and dry, and the pulse frequent, rising to 150 and 160, or higher, 
in infants, and to 140 and 150, or even 160, in those of several months 
old. The temperature rises very quickly, so that by the close of the 
first twenty-four hours it maj' reach 101°, 105°, or even 105.8° (Eoger). 
The dyspnoea becomes more and more evident. The respiration rises 
to 60, TO, 80, or even higher. In a case of pleuro-pneiimonia at six 
weeks of age, we counted it at 128. The breathing is at the same time 
more or less labored and difficult, the alse nasi being seen to dilate 
spasmodically at each inspiration, w^hile the miotions of the chest, and 
especiall}^ those of the abdomen, are much stronger and more active 
than in healthful respiration. The cough is now more frequent than 
before, evidently painful, and usually dry, though sometimes a slight 
degree of looseness may be detected in the sound which it occasions. 

Percussion now reveals manifest dulness over the seat of disease, 
which is usually the base, though not at all unfrequently the upper 
region of one side. When the disease is double, which is oftener the 
case, as already stated, in children than in adults, though not so often 
as has been supposed by some, the percussion will be dull of course 
over the affected region on each side. Together with the dulness of 
sound on percussion, and sometimes when this is faintly marked, there 
is an evident diminution of the elasticitj^ of the walls of the chest, and 
this becomes, therefore, an important symptom, especially when dul- 
ness on percussion is absent. The dulness on percussion is not, indeed, so 
marked a symptom in infants as in adults, from the fact that the natural 
resonance of the chest is so much greater in the former than the latter. 

Auscultation reveals over the diseased part distinct and abundant 
fine subcrepitant rale; but the crepitant rale or fine crepitation, which 
is the pathognomonic sign of pneumonia in adults, and which in 
them is rarely wanting, is absent in young children, or is heard only 
when they make deep and free inspirations. It is most apt to be heard 
in young children during the deep inhalations which they make just be- 
fore crj'ing, or during the act of crying. It is, therefore, much less 
constant, less stronglj^ marked, and more fugitive, in children than in 
adults, and is, in the former, replaced in good measure by a fine sub- 
crepitant rale. In connection with these symptoms we always have more 
or less well-marked bronchial respiration. This may be pure, which is 
rarely the case; it may be, as usually happens, associated with crepitant 
or subcrepitant rales, or it may be heard only in the expiration. 

The symptoms above described show that the inflammation has 
reached the second stage, or that of red hepatization. After attaining 
this point, the disease usually remains stationary for a few days, and 
then either subsides, in favorable cases, by the resolution of the inflam- 



SYMPTOMS. 171 

mation, or in unfavorable cases, terminates fatally in this stage, or else 
passes into the third stage and causes death by a more or less exten- 
sive suppuration of the lung. In favorable eases, which are said to be 
rare in very young infants, but more common in those several months 
old and in the second year of lile, the severity of the symptoms gradu- 
ally diminishes. The fever subsides, the pulse becoming less frequent, 
and the skin cooler and less dvy^ the breathing becomes easier and 
slower, and is attended w^th less pain; the cough grows looser, less 
frequent, less difficult, and ceases to be painful; the child begins to 
nurse without pain and with greater ease and facility; the restlessness 
and fretfulness, or the somnolence, when that has been a marked symp- 
tom, diminish, and the child becomes more placid, and sleeps quietly 
and tranquilly. The chest is now less dull than before on percussion; 
the bronchial resj^iration begins to diminish in intensity, and is very 
much masked by the subcrepitant rale, which becomes more and more 
evident, until at last it takes the place entirely of the bronchial breath- 
ing. The symptoms continuing to amend, the physical signs of the 
disease cease at length to be perceptible, the cough grows more and 
more loose and rare, the countenance becomes natural, the fever ceases, 
and convalescence is fully established. 

In unfavorable cases, death may occur rather suddenly in the second 
stage, without any very decided change in the physical signs, from 
exhaustion or from the supervention of collapse of portions of the lung- 
tissue. In these cases, the breathing becomes more and more rapid and 
labored, or it becomes slower than before; the moist rales increase in 
abundance and extent, while the percussion often remains about the 
same; the difficulty of sucking increases, so that the child, when put to 
the breast, attempts to draw but two or three times and then lets go 
exhausted and distressed, or it makes no effort whatever; the cough 
becomes less irequent, but is still painful and difficult; the skin grows 
pale and white, excepting about the face, hands, and feet, where it 
often assumes a bluish or cyanotic hue; the extremities, and often the 
iace too, become cool ; the child becomes exceedingly restless, and then 
dull and perfectly quiet or comatose, and death at last occurs from as- 
phyxia. In another class of cases, w^iich, however, are much more 
rare in very young children than in older ones, the disease j^asses into 
the third stage, or that of suppuration so called. In such cases the feb- 
rile s^-mptoms continue much longer than in those just now described; 
the pulse becomes, and continues for several days together, very fre- 
quent and jerking; the skin retains its heat and dryness, though it is 
often ])ale at the same time; the child is usually excessively irritable 
and distressed; the breathing is rapid and oppressed, and often very 
irregular and uneven; the dulness on percussion extends; the bron- 
chial respiration becomes more distinct and is heard over larger sur- 
faces, and is accompanied with less of the subcrepitant and crepitant 
rales; the cough is paroxysmal, painful, and often very harassing; the 
appetite is lost, and the sleep uneasy and often broken. These symp- 
toms continue for several days, or a week or two, when they assume 



172 PNEUMONIA. 

the same characters they exhibit in more rapidly fatal examples; that is 
to say, asphyctic phenomena develop themselves, and the child dies ex- 
hausted and comatose, or perhaps convulsed, or after presenting for 
some hours, or a day, more or less severe spasmodic aifections of differ- 
ent muscles or of the extremities. 

The lobar 'pneumonia of children over two years, and especially of those 
over five years of age, exhibits most of the symptoms that characterize 
the same disease in adults. The chief differences to be noticed at these 
two periods of life, are the greater predominance of bronchitis in chil- 
dren, particularly in those under five or six years of age, which gives 
to the physical signs some peculiar features not observed in adults; the 
frequent absence of expectoration, and when it is present, certain dif- 
ferences between it and that of adults; certain peculiarities in the char- 
acter and seat of the side-pain; and the existence in many instances of 
more marked and more dangerous nervous symptoms. 

The mode of onset is very diflPerent in different subjects. Generally, 
the attack begins with violent fever, increased frequency of breathing, 
more or less pain in the side, and short, dry cough. In such cases there 
is no difficulty in perceiving that the disease consists of some form of 
thoracic inflammation. But, in other instances, instead of this open 
and frank development, the disease comes on with symptoms which 
might well mislead any but a very attentive and competent physician, 
as to the true nature of the case. The most common cause of obscurity 
is a predominance of the nervous sj^mptoms, which often gives to the 
case very much the aspect of a meningeal inflammation. In an example 
that occurred to one of ourselves, a boy between six and seven j^ears 
old was seized, after a short exposure during a ride on a raw and cold 
day, with violent fever, pain in both ears, severe frontal headache, 
and great sensibility to light when exposed to it. He was, at the same 
time, very drowsy, sleeping nearly the whole day, but he could be 
roused when loudly and vehemently spoken to so as to answer a few 
questions and manifest great irritability, and, what was extremely sus- 
picious of disease of the brain, when taken with the other symptoms, 
he vomited frequently. On the second day, the headache was very 
severe, the sensibility to light continued excessive, and he still vomited 
frequently, rejecting even water. The bowels were freely moved. 
There was up to this time no full cough, but only an occasional and 
slight hacking, that scarcely attracted attention. The respiration was 
accelerated, but there was no dyspnoea. No pneumonia could be de- 
tected, though carefully sought after. On the third day, the breathing 
was still more frequent, but not at all laborious; the vomiting contin- 
ued, but the other nervous phenomena had lost some of their intensity, 
and auscultation revealed well-marked bronchial respiration before and 
behind, over the summit of the right lung, while over the same regions 
the percussion was dull. "We have met with several cases in which the 
onset of pneumonia was attended with nervous symptoms that made 
the diagnosis difiicult and obscure. 

In other cases the onset of the disease is marked by symptoms of 



SYMPTOMS. 173 

gastro-intestinal irritation, or by such a degree of fever and disturbance 
of the nervous system, with absence of evident local phenomena, as to 
render the nature of the attack obscure and uncertain. In one, for in- 
stance, occurring in a boy between four and five years old, and six 
weeks after recovery from measles, the attack began suddenly with 
violent fever, great restlessness and distress, vomiting, and distension 
of the abdomen. The case appeared to be one of gastro-intestinal dis- 
order, as there was nothing to call attention to the thorax. On the 
second day, the symptoms were much worse, the skin being hot and 
dry, and the pulse one hundred and sixty in the minute, and jerking. 
The child was drowsy and heavy; it was difficult to make him answer 
questions, and his answers were confused and unintelligible; his move- 
ments were tremulous and uncertain. The tongue was dryish and very 
thickly coated, and he complained confusedly of pain in the abdomen, 
which was much distended, and sonorous on percussion. There was no 
sign of respiratory disease, except quickening of the breathing, and 
a very slight cough, scarcely to be noticed. At this moment, how- 
ever, when scarlet fever was apprehended from the great frequency of 
the respiration, the drowsiness, and the tremulous character of the 
muscular movements, auscultation and percussion revealed the true na- 
ture of the sickness in the shape of a lobar pneumonia of the lower lobe 
of the left lung. 

In a majority of the cases, however, instead of the obscure and de- 
ceptive onset we have just described, pneumonia begins with fever, 
acceleration of the respiration, pain in the side, and short, dry cough. 
In some instances the disease supervenes upon catarrh or bronchitis. 
The child ceases to play, refuses to be amused, and is either irritable 
and cross, or lies listlessly upon the bed, or, if still quite young, insists 
upon being kept upon the lap. In some few cases, in very young 
children, convulsions occur. The appetite is lost, or else very much 
diminished ; the thirst is acute, and when the disease is once established, 
more urgent than in almost any other affection. Yomiting is quite 
common, especially in young children, but diarrhoea is rare, the bowels 
being generally more torpid than usual. From the first day often, 
and almost always by the second, we can perceive either crepitant or 
subcrepltant rale, and sometimes bronchial respiration, confined usually 
to one side, and more frequent below than above, though, be it re- 
marked, not at all rare over the latter part. 

As the case proceeds, the fever increases, the bronchial respiration 
becomes more distinct and is heard over a larger extent of surface, 
whilst the rales diminish in abundance. The skin is now very hot and 
dry, so as to impart a burning sensation to the hand; the pulse aug- 
ments in frequency, seldom counting less than 140 in the minute, often 
mounting to 160, and in severe cases, and in young children, even to 
170, and becoming full and hard; the respiration becomes more and 
more accelerated, until it rises to 40 or 50, and in a great many cases 
to 60, 70, or even 80, while it often becomes at the same time oppressed, 
and, when full inspirations are made, painful; the cough is frequent, dry. 



174 PNEUMONIA. 

or almost dry, and painful at first, but after a few days begins to be 
moist, and, in children over six or seven years of age, is not iinfre- 
quently attended with an expectoration of rusty or sanguinolent sputa; 
the thirst continues intense, the appetite is null, and the child is very 
restless and irritable, or drowsy and inattentive. About the fourth or 
fifth day, as a geiieral rule, the disease has attained its height, the 
febrile and local symptoms being then most marked, and the extent of 
the inflammation greatest, as shown by the physical sio-ns. 

At this stage of the disease, the bronchial respiration is generally 
strongly marked, being clear and distinct, audible both in inspiration and 
expiration, and accompanied by bronchophony and increased resonance 
of the ciy. The dulness on percussion is also very evident, the change 
from the natural sound being easily perceptible on a comparison of the 
two sides. 

The symptoms generally remain stationary at this point for one or 
two days, and then begin to subside. The heat of skin diminishes and 
perspiration often appears; the pulse falls in frequency and force; the 
respiration becomes slower, easier, and full inspirations can be taken 
without pain; the alas nasi no longer dilate; the cough becomes quite 
loose, and ceases to be painful; the thirst is less acute; the child loses 
some of its irritability and restlessness, and if it have been soporose 
and dull, becomes more wakeful and observant; the flushing of the face 
disappears, while the expression is more natural. On auscultation, 
the bronchial respiration is found to have lost some of its intensity; it 
has become more distant, or it is heard only in the expiration, and 
is mingled with, or in part replaced b}^ crepitant or abundant sub- 
crepitant rales. The dulness on percussion is less marked. A little 
later, the fever ceases entirely, the respiration reassumes its natural 
rate, the appetite returns, the thirst disappears, the cough subsides 
very much, and the child begins to be interested in its toys or occu- 
pations. About the tenth or fifteenth day, and in some cases rather 
earlier, convalescence is fairly established, though auscultation may 
still reveal some prolongation of the expiratory sound and difl'use 
resonance of the voice. 

In unfavorable cases, death seldom occurs early in the disease, but 
usually at some distance of time from the invasion, and in consequence, 
no doubt, of the transition of the inflammation into the third or sup- 
purative stage. In such cases the disease has usuall}^ pursued the 
course just described up to the period of resolution; but, instead of 
resolution and convalescence taking place, the fever continues, though 
perhaps with diminished violence, the skin being less intensely hot, 
and the pulse less full and active, while it remains quite as frequent. 
The breathing is sometimes less frequent than before, but it is often 
more laborious, and very generally it becomes irregular, and is easily 
hurried under exertion. The cough varies very much, being some- 
times almost suppressed, and in other cases very troublesome; it is 
almost always loose. The strength diminishes, the voice becoming 
weak and feeble, and the muscular movements tremulous and languid; 



SYMPTOiMS OF THE PARTIAL FORM. 175 

the face looks pale, haggard, and sunken; the child is sometimes very- 
restless, tossing about from time to time on the bed or lap, with a quick, 
short, and evidently feeble movement, or it is dull and soporose, awak- 
ening onh' when spoken to, but showing then by its fretfulness and 
peevishness that its intelligence is retained. While these symptoms 
are present, the extent over which the bronchial respiration is heard 
has generally augmented, showing the gradual extension of the hepa- 
tization, while outside of the part where the respiration is blowing, 
and sometimes over the same part, and intermingled with that sound, 
are heard more or less copious subcrepitant and mucous rales. This 
condition seldom lasts more than two or three days, at the end of which 
time the child dies in a state of coma, or after one or more convulsive 
seizures, which are the result of a gradually increasing asphyxia. 

In other cases, again, the termination is more gradual. The child, 
after presenting many of the above symptoms, may seem to improve 
somewhat. The fever may diminish, the appetite return to some ex- 
tent, the respiration become easier, the restlessness subside, and the 
child becomes more cheerful again ; but the face continues pale, emaci- 
ation makes progress, the appetite fails again, the pulse remains fre- 
quent, diarrhoea comes on, the cough becomes more troublesome, thrush 
often attacks the mouth, the strength decays continually, and, after 
some weeks perhaps of struggling, the child dies in a state of gi-eat 
emaciation and debility. 

The symptoms of partial pneumonia are much more obscure and un- 
certain than those of the lobar form of the disease. Owing to the fact 
that the inflamed patches of the lung are disseminated or scattered 
through healthy portions of the organ, the signs afforded by ph3'sical 
examination are citiier verj^ imperfect, or entirely masked by the 
sounds produced in the healthy texture. We are forced, therefore, to 
depend much more in this than in the lobar form, on the rational 
symptoms, in determining the nature of the sickness. The rational 
symptoms of partial pneumonia are nearly the same as those of the 
lobar form. The chief differences between the two are in regard to 
the pain, the dj'spnoea and, when there is expectoration, the amount 
of the sputa. The febrile and nervous symptoms, and the disturbances 
of the digestive sj'stem, are the same in the two forms, the only differ- 
ence being in their degree of severity. In the lobar variety they are 
usually more acute and severe than in the partial. The mere degree 
of temperature attained does not differ materially in the two forms, and 
it is not unusual to find a temperature of 104° or 105° on the second day 
of an attack of the partial form. Eoger {loc. cit.) notes, however, that 
while in lobar pneumonia the high temperature is sustained for six or 
seven days until defervescence occurs, in the partial form the course 
of the temperature is marked by a succession of irregular remissions 
and exacerbations. The local sj^mptoms present important differences 
which should be noted. In the form under consideration, the pain is 
either wanting entirel}^, or is much less acute than in the lobar form. 
When the inflamed patches are few in number, and they are seated in 



176 PNEUMONIA. 

the central parts of the lung, there is entire absence of pain- but when 
they are more numerous and superficial, pain is complained of, but it 
is usually diffuse, of slight intensity, changeable, and felt only during 
cough, or during full inspirations. It makes its appearance commonly 
on the first day, and very seldom after the third. Cough is rarely 
wanting. It usually marks the onset of the sickness, is extremely 
variable as to its frequency and severity, and is not acutely painful, as 
in the lobar form, unless the inflamed patches be superficial. There is 
seldom any considerable amount of expectoration, and in some cases 
none; when there is any it is small in quantity, and it may or may not 
be characteristic. In one case, however, that came under our observa- 
tion, in which we had every reason to believe, from the nature of the 
rational symptoms, and from the absence of phj^sical signs, that the 
disease was partial pneumonia, there was a rare expectoration of thick, 
viscous mucus, streaked with blood. The respiration is accelerated, 
and, when the lesion is at all extensive, there is dyspnoea, the degree 
of these symptoms being determined by the extent and number of the 
inflamed patches. 

The physical signs are not, as above stated, very significant. The 
percussion is natural, the amount of tissue consolidated being insuffi- 
cient to aff'ect the sonorousness of the chest. Auscultation affords no 
signs of the pneumonic inflammation w^hen the number of aff'ected 
patches is small ; when thej^ are more numerous it is of some, but not 
of very great utility. Crepitant rale is sometimes heard here and 
there over circumscribed points of the thorax, and, disseminated in the 
same way, there is also heard in some instances rude respiration, pro- 
longed expiratory murmur, and bronchial respiration. When, as often 
happens, this form of the disease coexists with bronchitis, it will be 
entirely concealed bj^ the dry and moist rales of the latter affection. 

The duration of pneumonia has been fixed with considerable accu- 
racy by the observations of various persons. As a general rule, the 
disease reaches its highest point of severity in about four or five days, 
then remains stationary for one or two days, and diminishes regularly 
until between the tenth and fifteenth day, when convalescence is es- 
tablished. In our own practice, the longest duration in 22 unmixed 
cases, in which the period was accurately noted, was 17 days, and the 
shortest 5. The duration of the 22 cases was as follows : in 1 case, 17 
days ; in 2 cases, 14 days ; in 1, 11 ; in 4, 10 ; in 5, 9 ; in 3, 8 ; in 2, 7 ; in 
2, 6 ; and in 2, 5 days. One case lasted 33 days, but it was accompa- 
nied and followed by bronchitis. 

Particular Symptoms; Physical Signs. — In order to practise aus- 
cultation and percussion in a young child, it should be placed, by the 
mother, in a sitting posture on her knee, while the physician, kneeling 
on the floor, or sitting on a low chair, makes the examination he deems 
necessary. If the child be old enough to take notice, it should be at- 
tracted and amused by some toy or glittering object. Even, however, 
should it cry violently, much valuable information is to be obtained 
by the examination, for we can ascertain the presence or absence of 



RATIONAL SYMPTOMS. 177 

rales and their characters during the deep inspirations between the 
cries, and can observe resonance of the cry and cough, and practise 
percussion. 

The physical signs of lobar pneumonia are crepitant or subcrepitant 
rale, feeble respiration, bronchial respiration, bronchophony^ resonance 
of the cry and cough, and dulness on percussion. They are, in fact, 
the same in the great majority of cases as in adults. Under five 
years of age. this form often begins with subcrepitant rale, while 
after that period the earliest stethoscopic signs are crepitant rale, 
or feeble respiration. The bronchial respiration makes its appearance 
soon after the subcrepitant or crepitant rale, is heard first in the ex- 
piration, and then in both inspiration and expiration, and is accom- 
panied by bronchophony, resonance of the cry and cough, and dulness 
on percussion. Bronchial respiration was present in 46 of the 57 cases 
of lobar pneumonia observed by ourselves; crepitant rale was present 
in 31, and subcrepitant in 10. 

These alterations of the auscultatory phenomena are confined to one 
side^ in the great majority of cases, and are best observed over the pos- 
tero-inferior portion of the lung. MM, Rilliet and Barthez state that 
they have never known the bronchial respiration to disappear, in favor- 
able cases, before the fifth day, and in the majority not before the 
seventh, eighth, or ninth ; while, in fatal cases, it continued to the 
moment of death. Its persistence is always a highly unfavorable symp- 
tom in very young children, whilst in those who are older, as in adults, 
it sometimes remains for several days or weeks, though the general 
symptoms have entirely disappeared. 

Eational Symptoms. — Cough may be said to be invariably present. 
It is dry at first, and not very frequent, but in one or two days becomes 
more frequent, often very troublesome, and from dry and harsh, becomes 
more or less humid and loose. It continues until the disease moderates, 
lasting generally from nine to sixteen days. In fatal cases it usually 
persists to the last. In infants it is not very frequent, occurs in short 
paroxysms, and in fatal cases often ceases one or two days before death. 
MM. Eilliet and Barthez remark that in pneumonia of the upper lobes, 
it has a peculiar character. It is little, short, smothered, as it were ; 
or piercing, teasing, or slightly hoarse. We will merely add that cough 
is sometimes scarcely noticeable in cases which simulate hydrocephalus, 
during the early part of the attack. In a case already referred to, that 
occurred to one of ourselves, in which the symptoms bore for several 
days very much the aspect of a meningeal attack, there was no full 
cough whatever during the first two days ; on the third day, though 
auscultation and percussion showed the existence of pneumonia of the 
upper lobe of the right lung, the child coughed only three or four times, 
and it w^as not until the sixth day that it became at all frequent. In 
three other cases the cough was so slight in the early stages of the dis- 
ease, during the continuance of the cerebral symptoms, as not to have 
been noticed unless particularly inquired after. Later in the attack, 
after three, four, or five days, and as the cerebral symptoms moderated, 

12 



178 PNEUMONIA. 

the cough became frequent and loose, and the pneumonic symptoms 
pursued their regular course. 

Expectoration is almost invariably absent under five years of age. 
MM. Eilliet and Barthez, and Dr. Gerhard, have never observed rust- 
colored sputa under the age mentioned. In older children there is 
sometimes, though not very often, voluntary expectoration. Even in 
them, however, the sputa seldom present the characteristic rust-color 
and viscidity observed in adults, but consist simply of mucus tinged 
with blood, or of whitish, brownish, viscous, or non-viscous phlegm. 
We once, however, saw a child three and a half years old, voluntarily 
expectorate viscid mucus, tinged copiously with blood. Sanguinolent 
expectoration was noticed in five of the fifty-seven cases seen by our- 
selves (not including the one just spoken of). In three the sputa were 
of the characteristic rusty color, in one they were composed of mucus 
streaked with blood, and in another portions of mucus streaked with 
blood were rejected by coughing, and some also by vomiting. The age 
of the five subjects, just alluded to, was in each case between five and 
nine years. In another case (not included amongst the five), in a girl 
seven years old, affected with lobar pneumonia supervening upon per- 
tussis, there was a free expectoration of tenacious mucus, sometimes 
streaked or dotted with blood, sometimes brownish, and sometimes rust- 
colored. 

M. Yalleix mentions a whitish or sanguinolent viscous froth, as some- 
times escaj^ing from the mouth of new-born children laboring under 
the disease, and Bouchut has also noticed in a single case, a little red- 
dish sanguinolent froth, situated on the edge of the lips of an infant 
with pneumonia. We have never met with this symptom, but know of 
one case of a child within the month, who, during an attack of pneu- 
monia, vomited mucus tinged with blood. The child died, and presented 
the lesions of pneumonia. The nipples of the mother were perfectly 
healthy, so that the blood could not have been sucked by the child from 
them, but must have consisted of the sputa which had been swallowed 
after being coughed into the fauces. 

It is scarcely necessary to say that the absence of expectoration is 
only seeming, for children undoubtedly cough the sputa into the fauces, 
whence, instead of being rejected, as by the adult, they pass into the 
stomach. 

Thoracic Fain. — It is impossible to ascertain the presence of this symp- 
tom with positive certainty prior to the age at which children talk, 
and very often not for some time after, as they refuse or do not know 
how to describe their sensations. And yet, even in infants, the presence 
or absence of the stitch in breathing, and of pain in coughing, may be 
inferred, almost with certainty, by watching the gestures and expres- 
sion of the child, and the cries which accompany a full inspiration 
and the act of coughing. In effect, the deep inspirations induced by 
moving the child, those which take place during vomiting and gaping, 
and those also Avhich occur in the act of coughing, cause the child to 
cry out suddenly and sharply, and give at the same moment an expres- 



RATIONAL SYMPTOMS. 179 

sion of acute suffering to the countenance, which can be referred to 
nothing else than the causes just mentioned, and which reveals almost 
as plainly as words the pain fulness of a deep inhalation and of the 
act of coughing. In older children, we have several times known the 
pain to be most intense, causing bitter and repeated complaints, with 
crying, fretting, and evident acute suffering. The seat of pain, as 
complained of by children who talk, ought also to be noticed, since the 
account given by them might well mislead an unwary and inexperienced 
phj'sician. It is quite common, in fact, for them to refer the pain to 
the false ribs, to one of the flanks, to the abdomen, and even to the hip. 

The respiration is always quickened, except where the constitution of 
the patient has been greatl}' deteriorated by long and severe illness or 
other cases, under which circumstances it may remain at the normal 
rate, or be very slightly accelerated. This symptom usually dates from 
the invasion, soon after which the breathing rises as high as 40, 50, and 
60 in the minute in older children, and from 60 to 80 in the younger. 
It sometimes becomes excessively rapid, reaching, as it did in a case of 
pleuro-j)neumonia in an infant six weeks old under our charge, 128. In 
favorable cases, the acceleration subsides usually about the seventh, 
eighth, or ninth day. In most of the cases the breathing is even and 
regular, while in others it is short, abdominal, uneven, and jerking. 
When the dyspnoea is very great in a young child, the nostrils dilate 
widely, the mouth remains open, and its angles are drawn downwards 
and outwards; the last of these symptoms is almost a fatal one. Some- 
times the rhythm of the function is changed, so that it begins with a 
sudden, active, and moaning expiration, followed by the inspiration, 
after which comes the interval of rest. MM. Eilliet and Barthez state 
that unequal, jerking respiration, occurs almost exclusivelj^ in cases of 
inflammation of the upper lobes. 

Physiognomy. — The face is almost invariably flushed. The color, at 
first scarlet, becomes after a day or two deeper and darker, and in se- 
vere cases assumes a livid-red tint. We have noticed in very severe 
pneumonia, in addition to the deep-red tint, a peculiar glazed appear- 
ance of the skin, which looks as though it had been varnished, while 
the edges of the flush are distinct and abrupt. The lips are generally 
deeply colored, simultaneously with the face. The flush commonly sub- 
sides about the same time, or a little before the diminution in the rate 
of the respiration. In fatal cases, the face is apt to lose its color, and 
become pale and sallow, as the unfavorable symptoms become more 
and more marked. The pallor of the face is most striking in severe 
and fatal cases occurring in infants; the face is blanched and the fea- 
tures pinched. 

The expression of the face is one of anxiety and oppression in the 
early stage; in very severe cases, or those about to terminate unfavor- 
ably, the features become drawn and contracted. 

Fever exists in all the idiopathic cases. The pulse, at all ages, is 
rarely under 130 from the first to the sixth or seventh day ; in the 
youngest children it rises as high as 140, 160, and even ISO ; while in 



180 PNEUMONIA. 

those who are older, it is seldom above 140. In favorable cases, it di- 
minishes about the fifth, sixth, or seventh day. In fatal cases, it is apt 
to diminish at the same period, but soon becomes more frequent and 
continues so to the end. 

The range of temperature in pneumonia is higher than in any other in- 
flammatory disease of children. This is true of the disease in both of 
its forms — lobar and partial. The highest temperature we have found 
recorded for pneumonia is 105.8°, which Eoger, in his latest contribution 
to this subject {Eecherches Cliniques sur les Mai. de VEnfance, 1872, p. 356), 
states was observed by him in 2 out of 47 cases of pneumonia. In 
two-thirds of the entire number the mercury reached or exceeded 104° ; 
and the mean of the highest temperatures in all the cases was 103.9°. 
Such high degrees are more apt to be found in children over than under 2 
years of age. The maximum temperature reached in any case would not 
seem to be much influenced by the seat or extent of the inflammation. 

In lobar pneumonia the course of the temperature is regular and 
characteristic. The accession of fever is often very sudden, and the 
mercury may rapidly rise to its maximum point, marking 104°, 105°, or 
even 105.8°, within twelve hours from the onset. After the first abrupt 
rise, it is sustained nearly at the same point, with moderate morning 
remissions and evening exacerbations (the variation usually not ex- 
ceeding one or one and a half degree) until defervescence, which is 
usually rapid, or even abrupt, occurs. In the partial form, on the other 
hand, the initial rise of temperature is less abrupt, and the course 
of the fever is marked by the occurrence of irregular remissions and 
exacerbations, which Eoger attributes to the development of successive 
patches of pneumonia. 

Usually the ratio between the temperature, pulse, and respiration is 
quite closely preserved, and an elevated degree of febrile heat is asso- 
ciated with marked acceleration of the pulse and breathing. Thus 
Eoger found that the mean furnished by 47 cases was: temperature, 
103.94°; pulse, 133; respirations, 52. It is not rare^ following the de- 
fervescence, to find the temperature fall below the normal jDoint, as to 
98° or 97°, for a day or two. 

The nervous system shows more or less marked symptoms of disorder. 
There is restlessness, peevishness, and irritability during the day, and 
these increase towards evening. As the night advances, the child be- 
comes still more restless; infants will not sleep except in the arms, 
and wake crying or fretting every few minutes or hours; older children 
sleep uneasily, talk in their sleep, or start and cry out, and are often 
delirious. In some instances, the irritability is most distressing, both 
to the child and to those around. The child is constantly fretting and 
whining; it wants its playthings, but will not touch them; food, but 
rejects it; and slaps and scolds at everything about it. Convulsions 
sometimes occur at the invasion. They last an uncertain length of 
time, and are usually followed by insensibility, from which the child 
wakes with fever, accelerated respiration and cough, indicating the 
true seat of disease to be the lungs, and not the brain, as might at first 



DIGESTIVE ORGANS — URINE. 181 

he supposed. We have met with but three cases attended with con- 
vulsions. One occurred in a boy between ten and eleven years of age, 
on the second day of the disease. The attack was induced more, how- 
ever, by an unwholesome meal taken on the first day of his sickness, 
than by the mere effect of the local inflammation. In a second case, 
which occurred in a boy between five and six years old, there were two 
convulsive seizures, a violent one on the first day of the pneumonia, and 
a slighter one a few days later. In the third case, which occurred in a 
boy aged two years, the pneumonia occurred in the course of intermit- 
tent fever- there were three marked convulsions, but the child subse- 
quently recovered perfectly. The headache is sometimes very severe; 
in a few instances we have known it to be so violent as to constitute 
the most prominent symptom of the case. On one occasion, indeed, it 
was so intense, and so much complained of, during the first two days 
of the fever, as to withdraw our attention from the true seat of disease, 
and it was not until the third day that we discovered the existence of 
pneumonia. The cough was in this, as in other instances, in which the 
nervous symptoms were strongly marked, so slight as to escape notice. 

Digestive Organs. — Complete anorexia is generally present from the 
first; the thirst is intense, greater indeed than in almost any other 
affection of childhood. The tongue is moist, as a general rule, and cov- 
ered with a whitish or yellowish fur. Yomiting and diarrhoea occur 
at the invasion of about half the cases in hospitals; in private practice, 
vomiting often occurs, but diarrhoea much less frequently. 

Urine. — The amount of urine is materially lessened in acute pneu- 
monia, the extent of the reduction being from one-third to one-half 
(Parkes). 

During the height of the disease the urea is increased, and with it, 
as in most febrile diseases, the uric acid. Simon and Eedtenbacher first 
called attention to the fact that the chloride of sodium is diminished or 
entirely absent during the early period and at the commencement of 
hepatization, and reappears during, or rather after resolution; and 
further researches have fully confirmed this observation, since very few 
exceptional cases have yet been recorded. The disappearance does not 
depend upon the reduced diet, since Howitz and Parkes both state that 
even when chloride of sodium is administered, none can be detected sub- 
sequently in the urine. And the fact that it is in reality retained in 
the S3'Stem, is further shown by the very excessive excretion during 
convalescence. According to Beale's observations, the exudation in the 
lung is very rich in chloride of sodium; and it has been found that as 
this salt disappears from the urine, it appears in the sputa, and in 
turn as it returns in the urine, it disappears from the sputa. 

It is true that more extended observation has shown that the chlo- 
ride of sodium is absent or deficient in many other affections, both 
febrile and inflammatory; but still, although not pathognomonic of 
pneumonia, this sign is an aid in its diagnosis, and probably serves to 
distinguish it from collapse of the lung or tuberculous consolidation. 

One more condition of the urine in pneumonia, although as yet, so 



182 PNEUMONIA. 

far as we know, only noticed in adults, deserves attention. "We allude 
to the presence of albumen, which has been noticed by several observ- 
ers, as Finger, Becquerel, Parkes, and Heller, in almost 45 per cent, of 
their cases; though others have but rarely found it. 

The period of its occurrence is variable; according to Heller and 
Parkes, it appears at the time when the chlorides are most deficient, as 
hepatization advances. The fatality is much increased in cases where 
albuminuria is present ; the combined record of the observers above re- 
ferred to, yielding a mortality of almost 50 per cent, of such cases; 
whilst the mortality in cases without albuminous urine was only 14 
per cent. According to Parkes, renal cylinders are very common in 
the albuminous urine of pneumonia; and a little blood is also frequently 
present, but is usually out of all proportion to the albumen. 

Diagnosis. — The lobar pneumonia of children is most liable to be 
confounded with bronchitis, pleurisy, and meningitis. There is little 
probability, however, that lobar pneumonia would be mistaken for 
bronchitis by any but a careless or incompetent observer; for the pres- 
ence, in the former, of subcrepitant, and very often, of crepitant rales, 
of bronchial respiration, bronchophony, resonance of the cry and 
cough, and dull or flat percussion, confined to one side, would easily 
distinguish it from bronchitis, which is marked by dry and moist rales 
over both sides of the chest, and by a normal condition of the percus- 
sion. It is difficult and often impossible, as already stated, to detect the 
existence of partial pneumonia, or at least to make the diagnosis with 
absolute certainty. The cause of the difficulty, as before explained, 
lies in the fact that it presents, in a great many instances, no clear phys- 
ical signs. When the number of inflamed nodules scattered through 
the healthy texture of the lung is small, and especially' when they are 
deeply seated, no alteration whatever of the natural respiratory sounds 
can be perceived, and we. are obliged to depend entirely upon the ra- 
tional symptoms, — the accelerated breathing, oppression, pain, cough, 
fever, and the absence of the physical signs of other pulmonary inflam- 
mation. A careful study of the temperature may here be of service. 
We have seen that in pneumonia the temperature usually rises quickly 
to 104° or 105°, while in bronchitis, it rarely attains even the lower of 
these, and often does not exceed 101° or 102°. Sometimes the presence 
of the characteristic sputa of pneumonia will, in older children, make 
the diagnc^sis clear. When the inflamed nodules are situated near the 
surface of the lung, we may, in some instances, detect crepitant or fine 
subcrepitant rale, and bronchial respiration, over circumscribed por- 
tions of the lung, and there would be, under such circumstances, no 
hesitation as to the diagnosis. 

It has been stated that pneumonia might be confounded with pleurisy. 
This could not happen in regard to the partial form, as the slighter 
degree of the pain, the limited extent of the rale and bronchial respira- 
tion, and the absence of dulness on percussion in the latter, would pre- 
vent such a mistake. The distinction between pleurisy and the lobar 
form is more diflficult, but may generally be made out by attention to 



DIAGNOSIS. 183 

the fact that pleurisy is rare under six years of age; by the greater 
severi-ty of the pain, the less abrupt and extreme elevation of tempera- 
ture, the absence of rales and presence of friction-sound, the effect of 
change of position on the sounds yielded by percussion, the shorter 
duration and greater mildness of the general symptoms, the entire ab- 
sence or small amount of expectoration, and by the continued dryness 
of the cough in pleurisy; and lastly, by the disposition on the part of 
pleurisy to become chronic, while pneumonia nearly always runs an 
acute course. 

Pneumonia in children not unfrequently simulates, in its early stage, 
an attack of meningitis, constituting a form of the disease sometimes 
called cerebral 'pneumonia. Yomiting, constipation, extreme irritability 
or restlessness, and complaints of headache, occur in both ; while the 
absence of thoracic symptoms to draw attention to the true seat of the 
disease in pneumonia, may readilj^ mislead. The cough in the early 
stage of pneumonia is sometimes very slight, and not being observed 
by the attendants, is not reported to the physician. The frequency of 
the respiration is overlooked, or, if noticed, is ascribed to the fever, 
which is supposed to depend on the cerebral inflammation. In pneu- 
monia, however, the vomiting is not usually very frequent, nor very 
obstinate, nor are the bowels so much constipated as in acute hydro- 
cephalus. These variations from the ordinary symptoms of the latter 
disease, minute though they be, ought to attract the notice of the 
physician, and lead him to examine the case more carefully when, in 
all probability, the physicalsigns would immediately reveal the pneu- 
monia. We may mention, in illustration, that we attended a boy six 
years old, who, for three days, suffered from violent fever and excruci- 
ating headache, which last was the only symptom complained of There 
was neither cough, expectoration, nor any marked acceleration of the 
respiration. After three days the headache, moderated, and he had 
slight pain in his side; on examination, we found him laboring under 
well-marked lobar pneumonia. In April, 1847, one of us was called to 
see a boy nineteen months old, who had been taken sick with slight 
fever, a little hoarse cough, and mild pharyngitis. After remaining in 
this condition for five days, he began to be drowsy and very irritable, 
the surface became pale, and the extremities rather cooler than natural. 
From the sixth to the tenth day, there was great somnolence, the child 
sleeping nearly all the time; when waked from sleep, he was always 
exceedingly irritable and cross, scarcely opening his eyes, and then 
shutting them again immediately to avoid the light, which was evidently 
painful. During this time he took scarcely any food, but little drink, 
and vomited several times freely; the bowels were moved without 
medicine; the surface remained very pale, and the extremities often 
cool ; the pulse was frequent and small, the respiration perfectly regular, 
for which reason it attracted no attention, and there was no cough what- 
ever. Under these circumstances, we hesitated between regarding the 
case as one of meningitis, or of hydrocephaloid disease, as described by 
Dr. M. Hall. We took the latter view, however, and treated it with 



184: PNEUMONIA. 

small quantities of brandy, cold to the head, and the frequent employ- 
ment of mustard pediluvia. From the eleventh day the child began to 
improve; it would open its eyes from time to time, and look round for 
a few moments ; the face began to show a slight degree of color, and 
the palms of the hands, which had been white and transparent, exhib- 
ited a tinge of the natural pink hue which they have in children. Ob- 
serving about this time that the respiration was accelerated, though 
perfectly free and regular, and without cough, we counted it, and were 
astonished to find it 80 in the minute. We now examined the chest 
carefully, and finding slight dulness on percussion with bronchial respi- 
ration, over the inferior half of the left side behind, immediately under- 
stood the nature of the case : it was one of latent pneumonia, simulating 
hydrocephalus. The child was now treated for pneumonia, and after 
an illness of twenty-seven days longer, recovered perfectly. As the case 
progressed, the rational signs of pneumonia were more and more ap- 
parent, the cough becoming frequent and painful, and after a time loose, 
while th»e cerebral symptoms gradually disappeared. 

In addition to these cases, we have met with several others which 
during the early stage resembled very closely the invasion of cerebral 
disease. One of these has already been referred to in the account of 
the symptoms of the disease. Two others occurred in children within 
the year, and one in a child between one and two years old. Atten- 
tion, however, to the rate of the respiration and the physical signs, 
and the presence of slight cough, revealed, in two of them, after a little 
hesitation, the true character of the attacks. The third case, which 
occurred in one of the children within the year, was unattended by any 
cough during the first few days, and was, therefore, very obscure, until 
our attention was attracted by an acceleration of the respiration, w^hen 
the physical signs, and, at a later period, the cough, explained the real 
nature of the attack. We may remark, in addition, that in all these 
cases, the absence of constipation, the infrequenc}?' and short duration 
of the vomiting, and some clearness of the intelligence when the child 
was fairly roused, though but for a few moments, from its state of 
somnolence, were other motives for doubting the attacks to be menin- 
gitis. 

We have dwelt at length upon the danger of making this serious 
mistake in diagnosis, in the hope that our remarks will aid in impress- 
ing upon the mind of our readers the great importance, which has 
indeed been alluded to on several previous occasions, of making a 
careful examination of the chest by auscultation and percussion in 
every case of acute disease in children, even though the symptoms 
do not appear to indicate any affection of the heart or lungs. 

Dr. AYest states that pneumonia is often overlooked in teething chil- 
dren, in whom the cough is called a tooth-cough, whilst the diarrhoea, 
which frequently occurs, and becomes the prominent sj-mptom, is sup- 
posed to depend upon dentition, and is alone attended to. The diar- 
rhoea is obstinate, and when, at last, the cough attracts attention, it is 
ascribed to phthisis, and the physician is astonished to find at the au- 



PROGNOSIS. 185 

topsy purulent infiltration of the lungs, but no tubercles, and no disease 
of the intestines. The diagnosis is to be correctly made, under such 
circumstances, only bj' careful physical examination. 

Prognosis. — It may be stated in general terms that pneumonia is 
the more dangerous in proportion as the child in whom it occurs is 
younger; and that the secondary, consecutive, or intercurrent form of 
the disease is much more dangerous than the primary. It is usually 
supposed to be almost necessarily fatal in new-born children, and to 
be still very dangerous up to the sixth year of age. There has been so 
'much confusion, however, in regard to atelectasis of the lung and true 
pneumonia until within a few years past, that it is scarcely possible to 
trust to former statistics upon this point. From six years of age up to 
fifteen, the disease is generally curable when of the primary form ; 
when of the secondary form the result is much more doubtful, and 
will depend in great measure, of course, on the nature of the disorder 
during or after which it occurs. 

M3I. Eilliet and Barthez (loc. cit,, p. 535) state that they lost about 
one-eighth of their cases in private practice. Of these, the youngest 
was a year old, the oldest, three years old. To quote their own words : 
''Some evidently died of accidents caused by the medication (poison- 
ing by tartar emetic) ; one was the victim of a relapse, due to faulty 
hygienic care ; and others died of cerebral pneumonia of the upper lobe ; 
they were undergoing the process of dentition.'^ In the hospital, they 
lost a seventh of their patients. The subjects under five years of age 
died of cerebral, gangrenous, or intestinal complications. Those over 
five years of age died, some because they were scrofulous or feeble, the 
inflammation, though lobar, being double; and the others, in conse- 
quence of the inflammation having become complicated with pleurisy, 
scarlet fever, or meningitis. They add, that in the hospital, six-sevenths 
of the patients attacked with secondary pneumonia died. 

In 1862^ however, Barthez stated, in a memoir to the French Acad- 
emy (3Ied. Times and Gaz., May 10th, 1862), that during the previous 
7 years, having abandoned the use of depletion in the pneumonia of 
children, he had treated 212 cases, with a loss of but 2 patients. 

The results of our own experience, which, it ought to be remarked, 
has been acquired chiefly in private practice amongst the easy classes 
of society, have been as follows : Of 65 cases of well-marked lobar 
pneumonia, only 2 were fatal. Of these two, one occurred in an infant 
six weeks old, and was accompanied with extensive and violent pleu- 
risy, and the other occurred in a child between two and three 3^ears 
old, lasted thirty-three days, and was attended with considerable bron- 
chitic inflammation. 

In addition to these, we have seen a certain number of cases which 
are not included in the statistics of our own experience, since some of 
them were only seen, and, perhaps, but a single time, in consultation, 
while others occurred among the children in the large public institutions 
of this city. A far larger proportion of these latter cases proved fatal. 

We may conclude, therefore, that pneumonia under two years of age 



186 PNEUMONIA. 

is always dangerous, and ranch more so when secondary than when 
primary; that primary- pneumonia, between the ages of two and five 
years, will, if treated judiciously, terminate favorably in the great 
majority of cases in private practice ; and that when the disease attacks 
children between six and fifteen years of age, the termination is nearlj^ 
always in health. 

The following are some of the most unfavorable symptoms of the 
disease: convulsions; small, weak pulse; extreme rapidity of the respi- 
ration ; persistence of the bronchial respiration in young children ; 
incomplete resolution of the disease within the ordinary period ; exces- 
sive and obstinate diarrhoea; severe cerebral symptoms; great emacia- 
tion ; greatly altered physiognomy ; excessive irritability ; and a yellow- 
ish tint of the skin. M. Trousseau regards as an unfavorable symptom 
the occurrence of swelling of the veins of the hands, which he supposes 
to depend on an obstacle to the function of haematosis. 

Treatment. — When one of the former editions of this work was pub- 
lished, fourteen years ago, a great change had begun to take place in 
medical opinion as to the proper treatment of disease, and especially of 
acute disease. In that edition this change of opinion was referred to, 
and its efi'ect upon our own convictions and methods of procedure freely 
acknowledged. Since that period this revolution, as it might be called, 
has continued to make progress, until, at the present moment, no one 
can candidly express his own views without referring to it. In view 
of these facts, we shall not hesitate to write at some length on the 
treatment of pneumonia, in order that our readers, and especiall}" the 
younger members of the profession, may be able to comprehend not 
only the changes that have taken place, but some of their causes. 

There is another consideration which has been forced upon us by 
time and experience, which makes us unwilling to dismiss the treat- 
ment of so important a disease in a few words, and this is, that the 
method of cure to be followed in individual cases must be determined 
not alone by the simple fact that the patient has an inflammatory exu- 
dation in the lung-tissue, but, in large measure, by the state of the 
general vitality of the subject. What folly, for instance, to suppose 
that we can safely apply the same therapeutic measures to a case of 
pneumonia in a child just issuing out of severe measles, to one in the 
midst of a dangerous typhoid fever, to a third in the spasms of hoop- 
ing-cough, or to a fourth who was yesterday in consummate health, 
with every function, up to the moment of the attack, in the finest pos- 
sible working order. To be sure, this is putting the case in very 
strong terms, but they are not too decided to make our meaning clear. 

Moreover, we think there is a tendency, in some of the later works 
on diseases of children, and in some, too, of the general treatises on 
the practice of medicine, to lengthened scientific descriptions of ana- 
tomical changes, sjnnptoras, diagnosis, &c., and to a corresponding 
diminution of the space devoted to therapeutics. This error, as we 
think it (not to be wondered at, perhaps, when we consider the rela- 
tive difficulty of writing on these different subjects), we desire to avoid, 



TREATMENT — BLOODLETTING. 187 

and, indeed, we bave found it impossible to state our opinions on tbe 
subject except at some lengtb. 

Bloodletting. — Twenty years ago depletion formed an almost inevi- 
table item in the treatment of pneumonia, but, within tbe last eight or 
ten years, tbe views of most observers have undergone a more or less 
radical change in regard to its utility and necessity. Some have 
abandoned it altogether; others employ it still to a moderate extent. 
In order that the younger practitioner may see the changes which 
have taken place in this respect, we shall quote the views of some of 
the more important authorities, and then give our own. 

Dr. Charles West (4th Am. ed., from 5th English ed., page 285) writes 
as follows : "I cannot forget the good results which I saw years ago from 
the abstraction of blood at the outset of an attack of pneumonia in pre- 
viously healthy children." He, however, does not advise depletion when 
small crepitation has become generally diffused, still less when diilness or 
bronchial breathing is perceptible. He gives no statistics as to his own 
results whatever. Dr. J. Lewis Smith, of New York, in his w^ork, does 
not even mention bloodletting. Dr. Thomas Hillier, of London, says 
of bloodletting that it "is now for the most part discarded. I have 
never had occasion to resort to it." He says further, however, that 
cases might occur where it would be proper to recommend it. Such 
conditions would be, the second day of the disease, a large extent of in- 
flammation of the lung-tissue, full and bounding pulse, great pain and 
dyspnoea, and a temperature of 105° or more. If these conditions ex- 
isted in a previously healthy child, he would think itwise to take a 
few ounces of blood from the arm. We have already referred to the 
communication from M. Barthez to the Academy of Medicine of Paris, 
in April, 1862, intended to vindicate the expectant treatment of pneu- 
monia in early life. In this paper it is stated that of 212 cases of lobar 
pneumonia, occurring between the ages of two and fifteen, in the course 
of seven years, at the Hopital Ste. Eugenie, only 2 had a fatal termi- 
nation, although no approach to active treatment was adopted in more 
than a sixth of the number. Dr. J. Hughes Bennett gives, in The Prac- 
titioner, for May, 1869, the results of the restorative treatment of pneu- 
monia in 153 cases. Of these, 129 were simple and 24 complicated 
cases. Of the 129 simple or uncomplicated cases, of which 35 were 
double, all recovered. Among the 24 complicated cases there were 5 
deaths, making of the whole number a mortality of 1 in 30|- cases. Dr. 
Bennett's cases all occurred in adults, but the results are useful to us as 
showing the effects of this kind of treatment. 

In a former edition of this work it was stated that one of us had 
treated 50 cases of well-marked lobar pneumonia, with 2 deaths, in pri- 
vate practice. Full notes of only 46 of these cases were kept. Of the 46 
cases, 39 w^ere primary or uncomplicated, and 7 secondary or compli- 
cated. The 2 fatal cases occurred, one at six weeks old, and this was 
attended with very severe pleuritic inflammation, and the other between 
two and three years old ; the latter case lasted 83 days, and was at- 
tended with considerable bronchitic inflammation. Depletion was em- 
ployed in 16 of the 39 primary, and in 2 of the 7 secondary cases. It 



188 PNEUMONIA. 

is proper to state that depletion was DOt employed in either of the fatal 
cases. 

How difficult is the task of estimating the comparative value of differ- 
ent plans of treatment in any given disease. MM. Eilliet and Barthez 
lost one-eighth of their cases of pneumonia in private practice, and one- 
seventh in hospital. We lost one- twenty-fifth of ours in private prac- 
tice; a result ver}" nearly as good as Dr. Bennett's, though ours were 
all in children under 15 years of age, and of 37, whose ages were re- 
corded, 19 were under 5 years (2 in the first year, 3 in the second, 5 
in the third, 4 in the fourth, 5 in the fifth). Dr. Bennett condemns 
bleeding almost wholly; we took blood in 16 of 39 primary, and in 2 
of 7 complicated cases, and did not deplete at all in the 2 fatal cases. 
M. Barthez reports 212 cases, treated by the expectant method, with 
onl}^ 2 deaths, or less than one in a hundred ; and these cases, too, in 
children between 2 and 15 j^ears of age, in hospital practice. These 
last statistics are the most surprising we have seen. We have been 
unable to find the original memoir of M. Barthez, but have seen the 
report made to the Academy of Medicine, by M. Blache {Bulletin de 
VAcad. Imp. de Medecme, t. xxx, p. 21), on the memoir, in which it is 
stated that "the author has taken care to eliminate the lobular or gen- 
eralized pneumonias, the pseudo-lobar pneumonias, broncho-pneumo- 
nias, and catarrhal pneumonias; he has also thrown aside the lobar 
congestions which occur in the course of low fevers, and the secondary 
lobar hepatizations; that is to say, those which occur in the course of 
any well-determined disease, and particularly tuberculosis." We can- 
not help thinking that the elimination of so many forms of pneumonia, 
must be a chief reason for the very great success of the plan of treat- 
ment used. 

This much, however, has been plainly established by the observations 
and experience of late years, that the old plan of bleeding, as a rule of 
absolute practice, merely because of the existence of pneumonia, and 
especially the Sangrado system of bleeding, coup sur coup, was a gross 
mistake, and one which did great harm. But we do not think it has 
been proved that the restorative or expectant system, to the exclusion 
of bloodletting under any circumstances, is always and inevitably the 
right one. We have been led to think that bloodletting was not the 
only cause of the heavy mortality under the old systems of treatment, 
but that the use of such agents as antimony, ipecacuanha, and perhaps 
calomel, in large and frequently administered, and long-continued doses 
(and particularly the antimony) by their action upon the stomach, in 
destroying all power to take and digest food, and by the general pros- 
tration which their action (especially antimon}^) upon the nervous sj^s- 
tem occasioned, were answerable for a large share of the fatal results 
of those days. We doubt, in fact, whether depletion, used in anything 
like moderation, is not safer for the patient than the continued use, for 
two or three days, of nauseants and depressants, more particularly of 
antimon}^ But of the action of antimony upon children, we shall speak 
more at length hereafter. 

Our own opinion, after the enlarged experience of later years, is, that 



TREATMENT — BLOODLETTING. 189 

depletion should not be used save in exceptional cases. When the pneu- 
monia is pursuing a regular and safe course, it is best to trust to the sim- 
ple means to be spoken of hereafter — to follow a mild expectant method. 
Where the physician doubts as to its propriety, and especially when he 
is young and inexperienced, it is safest to abstain from it entirely, or to 
employ it only in a very moderate degree. But there is a certain class 
of cases, in which we believe that local depletion, by cups and leeches, 
is not only allowable but most useful.. When the subject is vigorous and 
strong, with a fine sanguification; when the temperature is very high; 
the pulse strong and full ; the muscular force good, and the side-pain and 
cough very severe, we think that the local abstraction of from two to 
four ounces of blood, at the age of three or four years, has great power 
to relieve all these symptoms. x\gain, when the dyspnoea is very great; 
when the heart pulsates with great force, Avhilst the pulse is small and 
feeble, showing that the right heart is overloaded, and the arteries com- 
paratively empty, in consequence of obstruction to the passage of blood 
through the lungs; and when the child is tolerably vigorous, and not 
reduced by previous illness, a moderate venesection is often of more 
use, and of more efficacy in palliating these conditions, than any treat- 
ment we know of. The quantity to be taken should seldom be over 
four ounces, at the ages of from three years and upwards. We venture 
upon these statements the more boldly when we find such men as 
Chambers and JS'iemeyer, and even Bennett, giving the same advice. 
Dr. Bennett {loc. cit.) lays down amongst his axioms the following: 
"Small bloodlettings, of from six to eight ounces, may be used in ex- 
treme cases, more especially in double pneumonia and broncho-pneu- 
monia, as a palliative to relieve tension of the bloodvessels and conges- 
tion of the right heart and lungs." Niemeyer (^Text-Book of Pract. Med., 
Amer. ed., vol. i, p. 184) says, pithily: "Highly as I prize venesection, 
however, in certain emergencies which may arise in the disease, I had 
rather that any one, dear to me, and sick of pneumonia, were in the 
hands of a homoeopath, than in the hands of a physician who thinks 
that he carries the issue of the malady upon the point of his lancet." 
He recommends venesection in three conditions : 1. When the pneu- 
monia has attacked a vigorous and hitherto healthy subject, is of re- 
cent occurrence, the temperature being higher than 105° F., and the 
frequence of the pulse rating at more than 120 beats a minute. "Here 
danger threatens from the violence of the fever, and free venesection 
will reduce the temperature, and lessen the frequence of the pulse. In 
those who are already debilitated and anaemic, bleeding increases the 
danger of exhaustion. Should the fever be moderate, bloodletting is 
not indicated, even in healthy and vigorous individuals." 2. "When 
collateral oedema, in the portions of the lung unaffected by pneumonia, 
is causing danger to life, the pressure of the blood is reduced by bleed- 
ing, and by prevention of further transudation of serum into the vesicles, 
insufficience of the lung, and carbonic acid poisoning are averted. When- 
ever the great frequence of respiration, in the commencement of pneu- 
monia, cannot be traced to fever, pain, and to the extent of the pneu- 



190 PNEUMONIA. 

monic process alone, as soon as a serous, foamy expectoration appears, 
together with a respiration of forty or fifty breaths a minute, and when the 
rattle in the chest does not cease for awhile after the patient has 
coughed, we ought at once to practice a copious venesection, in order 
to reduce the mass of blood, and to moderate the collateral pressure. 
The third indication for bleeding arises upon the appearance of symp- 
toms of pressure upon the brain, not headache and delirium, but a state 
of stupor or transient paralysis." We have made this long quotation 
because the authority is so high, and because we have nowhere found 
such clear and concise statements upon this most important point of 
practice. 

Antimony. — In a former edition of this work it was stated that tartar 
emetic, in the dose recommended by some of the highest authorities of 
the day, had been found by us a very dangerous drug. Time has but 
confirmed this oj^inion. At that time we were in the habit of adminis- 
tering it in doses of a forty-fifth or sixtieth of a grain every hour or two 
hours. This was at a time when Killiet and Barthez used it in doses of 
from two to four grains, dissolved in four ounces of water, in twenty- 
four hours, for very young children, and for those who were older six 
grains in the same space of time. They continued it for two^ three, or 
four days, and advised its suspension should it give rise to excessive 
vomiting or severe diarrhoea. Dr. West at that time gave it in doses 
of one-eighth of a grain, at the age of two years, every ten minutes, 
until vomiting Avas produced; to be continued every hour or two after- 
wards for a period of twenty-four or thirty-six hours. Dr. West had 
reduced the doses, and the time of continuing it, one-half, between the 
time referred to and the date of his essay on pneumonia, published in 
1843. 

The doses used by us, as mentioned above, may seem to some who 
have not employed them ludicrously small, but we soon found that 
even they were quite frequently, in certain constitutions, more than 
could be given with safety. Antimony, even in those small quantities, 
sometimes caused a very peculiar general prostration. Perhaps with- 
out any vomiting whatever, or with only a rare effort at that act, the 
patient would refuse all nourishment, become very pale and weak, grow 
limp and motionless, take on a haggard and pinched expression of face, 
pass into a state in which it would pay no attention to what was going 
on around, be very peevish and irritable when disturbed, get a very 
frequent and feeble pulse, and look to an experienced eye as though 
a very little deeper degree of such prostration might end fatally. After 
seeing this condition a few times, and finding that the withdrawal of 
the drug and the use of small doses of brandy (ten to twenty drops in 
water or milk) every hour or two hours, was followed by rapid im- 
provement, we learned the greatest caution in the use of the remedy. 
Of late years we never use tartar emetic at all, but give, not unfre- 
quently, in strong and vigorous children, with high febrile heat and 
rapid circulation, small doses of the precipitated sulphuret of antimony, 
always watching its effects carefully, and withdrawing it at once should 



TREATMENT — ANTIMONY — IPECACUANHA. 191 

the above symptoms make tbeir appearance. The formula found most 
useful and safest is the following : 

R. — Antimon. Sulpliurat, . . . • gr. j. 

Pulv. Doveri, gr. iij. 

Sacch. Alb., gr. xij. 

M. et div. in chart, no. xii. One to be given every two, three, or four hours. 

To infants under two years of age it is best to give no antimony at 
all. 

Calomel. — In former years, in obedience to the prevailing rules of the 
day. we gave calomel in very moderate quantities in some cases of 
pneumonia. We never felt sure that it was of any special service, and 
of latter years have abandoned it altogether. It is one of the drugs 
which, we think, ought not to be given except under some very clear 
indication. Such indications rarely exist in pneumonia, and therefore 
we do not prescribe it. 

Salives. — Citrate of potash, either in the form of the neutral mixture 
or dissolved simply in water with a little sugar, is one of the best feb- 
rifuges that can be used. In doses of two and a half grains to children 
over three or four years old, and half a grain to a grain for younger 
children and infants, every two hours, it is an excellent remedy. It 
may be given alone, or combined with small doses of syrup of ipecacu- 
anha and opium. Spirit of nitrous ether maj^ be added when the urine 
is scanty, or when the ipecacuanha cannot be borne. 

The solution of acetate of ammonia, either alone or combined with the 
spirit of nitrous ether, is useful when the child is feeble^ and when the 
stomach or bowels are irritable, in which case the citrate of potash 
sometimes offends the stomach and acts upon the bowels. The dose of 
this remedy may be from twenty or thirty drops to half a drachm or 
a drachm, according to the age, in sweetened water, or some aromatic 
water, every two hours. 

Quinia is unquestionably a remedy of great value in the pneumonia 
of children. When given in full doses, it diminishes the intense febrile 
heat and the great rapidity of pulse; and, at the same time, is believed 
by many observei-s, to possess a tendency to check the extension of the 
exudation process. It is usually perfectly well accepted by the stom- 
ach, and does not interfere with the power of taking food; w^hile, on 
the other hand, by its tonic influence it must be of service in sustaining 
the system until the necessary stages of this exhausting disease have 
been passed. 

Ipecacuanha is j^referable to antimony in all conditions except those 
referred to above. In infants under two years of age, in children of 
highly nervous temperament, or of feeble and delicate constitutions, in 
most cases of the secondary form, and in all mild cases, it is much safer 
than the other drug. The most convenient preparation is the syrup, of 
which ten drops may be given every two hours at four years of age, 
five drops between one and three years, and from one to three drops to 
infants of two or three months. It is often useful to combine the spirit 
of nitrous ether with it, and, when the stomach is irritable, or the pa- 



192 PNEUMONIA. 

tient very restless and irritable, to add sraall doses of opium. "When 
the patient is much oppressed by the presence of secretions in the bron- 
chia, and not too much prostrated, an emetic is often very useful. Ipe- 
cacuanha is the most suitable remedy for this purpose, as it j^roduces 
less exhaustion and depression than any other, except, perhaps, alum. 

Muriate of Ammonia has of late years been very largely employed in 
the acute pulmonary affections both of adults and children. It has 
seemed to us to possess the power of hastening the softening and reso- 
lution of the exudation, and, "when there is expectoration, of rendering 
it less viscous and freer. The best period for administering it is after 
the hepatization is clearly established and the attack has reached its 
full development. It may then be given, associated with the febrifuge 
employed, or else dissolved in a little syrup of Tolu or syrup of wild 
cherry bark and water. The proper dose is one grain for children 
under 2 years of age, and 2 to 3 for those between 2 and 5 years, given 
every 6, 5, or 4 hours, according to its effect and the way in which it is 
tolerated by the stomach. 

Purgatives. — A purgative dose is useful at the beginning of the attack, 
when the child is constipated, and when the abdomen is tumid and hard. 
A teaspoonful of castor oil, or two teaspoonfuls of simple syrup of rhu- 
barb, will answer every purpose. After this period cathartics need be 
used only so as to keep the bowels moderately soluble. If they are 
moved spontaneously every two or three days, there is no occasion to 
give j^urgative doses. If they do not move, a simple enema, or the doses 
mentioned, will be sufficient. Violent or frequently repeated doses of 
purgatives are injurious, by exhausting the patient through the disturb- 
ance of the stomach which they occasion, or by setting up diarrhoea. 

External Applications. — M^l. Eilliet and Earthez were of opinion that 
neither blisters, Burgundy pitch, nor tartar-emetic plasters, exerted 
the least influence upon any one of the symptoms of pneumonia, but 
that, on the contrary, they increased the fever. Dr. West gave up the 
use of blisters entirely, in consequence of the irritation and fever they 
occasioned, and because of the disposition to sloughing which he ob- 
served to follow their use amongst the poor. At one time we thought 
we had observed great benefit from the use of a blister when other 
means had failed to produce some moderation of the symptoms after 
four or five days. If they are used at all, it ought to be with great 
care, especially in very young or feeble children, whose nutrition is 
depraved. In children of less than two or three years old, a blister 
should never remain on the skin longer than two hours. As a general 
rule, the mother should be told positively to remove it at the end of 
one hour and a half, even though the surface be still unchanged. A 
warm bread-and-milk poultice is then to be used as a dressing, and this 
rarely fails to cause vesication in a few hours. Employed in this way, 
we have had but once the misfortune to see a blistered surface slough, 
and this occurred in a child whose skin had been very much irritated 
by frictions with amber oil and ammonia. 

Since the spring of 1845, however, when we were led to make fre- 
quent use of mustard poultices and foot-baths in the treatment of the 



TREATMENT — LOCAL APPLICATIONS. 193 

bronchitis and pneumonia of measles, we have rarel^^ employed blisters, 
but have preferred the employment several times a day of the reme- 
dies jnst indicated. Two parts of Indian meal and one of mustard, for 
young children, and for those who are older equal parts of each, are to 
be mixed with warm water, and spread thickly like a poultice on a 
piece of flannel or rag five or six inches square. This is to be covered 
with fine muslin, linen, or gauze, and applied fir^st over the back and 
then the front of the thorax. It may remain from fifteen to forty 
minutes, or until the child cries or complains, or until the skin is red- 
dened. The mustard foot-baths may be employed at the same time 
with the poultices. These applications are useful whenever the op- 
pression is very great, and, when resorted to in the evening, they often 
allay irritability, and dispose the child to sleep. The number of appli- 
cations to be made in a day must depend on the urgency of the symp- 
toms. We have employed them from once a day to every two or three 
hours. 

Dr. Chaaibers (loc. cit.) strongly recommends the use of linseed-meal 
poultices, as a " direct restorative means, about the use of which also 
anywhere you need have no manner of hesitation." He claims that it 
alias's the pain ; relieves dysj^noea ; induces moisture and activity of the 
skin; and promotes the absorption of the exudation. He directs the 
poultice to be spread half an inch thick on a cloth or flannel as broad as 
the circumference of the thorax, and deep enough to cover the whole 
chest, from the collar bones to the hypochondria. In adults this will 
usually keep in place of its own accord, but in children you should have 
a tape stitched on in front, and a tape behind, which you can tie over 
the shoulder in the manner of a shoulder-strap. 

Tonics and stimulants are to be resorted to in cases which manifest 
undoubted signs of debility. When, therefore, the attack occurs in a 
feeble child; in secondary cases; when the inflammation remains unre- 
solved after the use of other remedies, and when extensive bronchial 
respiration persists, though the fever has moderated ; or when, in any 
case, during the acute stage, the child falls into a typhoid state, as 
shown by pallor of the surface, frequent, uneven pulse, dry tongue, 
prostration of muscular power, and either incessant jactitation or the 
listless quiet of exhaustion; attention must be paid to the state of the 
constitution even more than to the local disease. The vital forces must 
be sustained and strengthened in order to give time and power to carry 
on the operations necessary for the removal of the local obstruction. To 
effect this purpose, we must depend upon the use of food, alcoholic 
stimuli, and certain tonics. The food most suitable for such a condi- 
tion is milk, animal broths, soft-boiled eggs, and perhaps small quanti- 
ties of raw or slightly cooked meats. The best stimulants are brand}', 
given either in the milk or in water, as the child will best take it, and 
wine and water, or wine-whey. The amount of brandy given may be 
stated as 3, 4, or 5 teaspoonfuls in the course of 24 hours at 4 years of 
age. The best tonic to give in conjunction with the alcoholic stimulus 
is, as has already been stated, quinia^ which should be administered in 

13 



194 PNEUMONIA. 

the quantity of from gr. iv to gr. vj in 24 hours, given in divided doses. 
When the exhaustion is marked, especial!}^ when associated with great 
embarrassment of respiration and copious viscid secretion from the 
bronchial tubes, we should recommend the use of the muriate of car- 
bonate of ammonia, either of which may be given in mucilage, in doses 
of gr. ij to iij every 3 or 4 hours, at 4 or 5 years of age. 

Opium is constantly of great service in the treatment of pneumonia. 
It should always be used when the patient suffers much, either from 
the side-pain or from cough, whether this be harassing and exhausting 
from its mere frequency and persistence, or from its effect in develop- 
ing the stitch ; when there is painful jactitation, an unusual degree of 
distress and malaise, or marked tendency to morbid vigilance. When 
the fever is very high, the pulse vibrating, the nerves on a rack, opium 
is of the greatest advantage. The mere comfort it gives is a good war- 
rant for its use, but it has long seemed to us to aid in shortening the 
duration and lessening the severity of the constitutional disturbance. 

The choice of the preparation, and the doses and times of administra- 
tion, must vary in different cases. When used early in the case, to act 
upon the circulation and allay general irritability, it is best to give it with 
the febrifuge every two or three hours. When used to control cough, 
it can be added to the sulj^hurated antimony in the form of Dover's 
powder, as already suggested, or to the syrup of ipecacuanha and spirit 
of nitrous ether, in a liquid form; or, when the congh is particularly 
troublesome at night, as often happens, it can be given with more ad- 
vantage in a single dose, or two doses in the evening. The prepara- 
tions we have found most useful are, laudanum, especially the tr. opii 
deodorata, paregoric, solution of morphia, or Dover's powder. Under 
six months of age, half a drop of laudanum, from five to ten drops of 
paregoric, or two or three drops of the solution of morphia, may be 
given, and repeated twice or three times in the twenty-four hours, ac- 
cording to the effects. From the age of six months to the end of the 
second year, these doses may be doubled. In the third and fourth 
years, two drops of laudanum, ten to twenty of paregoric, five to ten 
of solution of morphia, may be used several times a day. Where the 
remedy is given every two or three hours, we have found one drop of 
laudanum quite enough at the ages last mentioned. When the dose is 
given only at night, from three to five drops of laudanum, ten to fifteen 
of solution of morphia, and thirty to fifty of paregoric are sufficient as 
a general rule. After the age of four and five years, the doses must 
be increased in proportion to the age. In very young children, the 
doses given at first should alwaj^s be watched with a good deal of care, 
and never carried to such a quantity, or continued long enough, to in- 
duce constant and heavy drowsiness or stupor. In some instances of 
very nervous and hypersesthetic children, in whom there is determined, 
by the violence of the reaction, a degree of irritability of the nervous 
centres tending to the tetanic state, the doses must be much larger than 
those mentioned ; but here the physician should see the patient himself 
at least twice, and sometimes three times in the day, "to watch and 



USE OF OPIUM — GENERAL MANAGEMENT. 195 

regulate by the dose the exact action of the drug. We have occasion- 
ally seen the cough most harassing and exhausting in its effect, occur- 
ring almost with every breath, and lasting for twelve and twenty-four 
hours. Under such circumstances, a mixture like the following has 
proved most beneficial in our hands: 

R. Tr Opii Deodorat., gtt. xxxij. 

Vin. Antimon., gtt. xxxij. 

Ext. Talerian. FL, f^ij. 

Svrup. Simp., f^ij. 

Aqufe, f^iss. — M. 

Dose, a teaspoonful every hour or two hours, at the age of four years and upwards, 
until the cough is controlled. 

Paregoric, in the proportion of two drachms to half an ounce, in place 
of the laudanum, sometimes proves more soothing and comforting. 

General Management. — Since the reign of restorative medicine has 
set in, the general management of the patient has received a degree of 
attention which it had never attracted before. Under the expectant 
plan it constitutes, indeed, the chief portion of the treatment. The 
most important points to be attended to under this head are the diet, 
drinks, clothing, air, and state of repose. 

The patient ought not to be allowed to go entirely without food even 
in the early days of the disease, neither should there be any eifort 
made to stuff the child with large quantities of nourishment. The ap- 
petite is nearly always in great measure abolished, at first, and food is 
unwillingly taken except in very small quantities. A nursing child 
must not be allowed to nurse as heartily as usual. If it attempts to do 
so, it is probably from thirst and not from hunger. Water, therefore, 
should be offered to it from time to time, and the breast be allowed 
only every three or four hours for short periods. Weaned children 
should have only milk, always reduced by the addition of half or a 
third water, and pure water ought to be given frequently. The thirst 
in this disease is intense, and the physician should himself see that the 
patient has water freely. We have seen the most violent and obstinate 
screaming, and painful restlessness, quieted at once by a copious 
draught of cold water. In children over two and three years of age, 
milk and water is still the best food; but when this is refused, thin 
chicken or beef tea may be given in doses of a wineglassful or a gill 
every four hours. After three or four days have passed by, the admin- 
istration of food is a very important part of the treatment. The child 
shojild now be induced, by persuasion and even gentle force, to take a 
little food at least three or four times in the twentj^-four hours. As 
the severity of the symptoms subsides, the food ought to be increased 
in quantity. 

The clothing ought to be such as to keep the body comfortabl}^ warm. 
In winter, which is the season when the disease almost always occurs, 
thin and soft flannels ought to be worn, and, when the child is very 
restless, either in the bed or on the lap, a sack made high in the neck, 



196 BRONCHITIS. 

with the sleeves to the wrists, buttoning in front, and consisting of a soft 
and pliable woollen stuff, ought to be put over the bed-dress. 

The room ought to be, if possible, a large one with a high ceiling, 
well ventilated, warmed by an open fire, and kept at a temperature of 
65° to 68°. If the child is very young and delicate, a temperature of 
70° is not too high, if only the ventilation be good. 

The bed or crib is the proper place for a child with pneumonia. The 
lap of the mother or nurse is a poor substitute for an even, elastic, and 
steady matti-ess. We have long endeavored to keep our little patients 
in bed. A very young infant must of course often be taken up to be 
nursed, soothed, or cleansed, but, as soon as possible, it ought to be re- 
placed in the crib. Children a year or two old can generally, with good 
management, be kept the greater part of the time in bed. Those of 
three and four years old and upwards ought always to be confined to 
the bed. A little firmness on the part of the mother will almost always 
accomplish this end, and it is a highly important one, and well worth 
even a quarrel at the beginning of the sickness. We have seen a child 
three years old kept by a weak and overtender mother and grand- 
mother nursed on the lap for three weeks, until they w^ere exhausted 
and demoralized, and the child had oedematous feet from their depend- 
ent position during so long a time. 

Eepose and quiet of mind and body, as complete as can be attained, 
are things of great value, and to secure them a good bed and a cheer- 
ful and resolute manner on the part of the nurse are as important for 
the child as for the adult. It is only in bed, too, that an even tempera- 
ture and an avoidance of draught can be fully secured. A direction 
given by some of the French writers, and by Dr. Gerhard, is not to 
allow very young children to lie for too long a time in one position in 
bed. or in the nurse's arms, as it is apt to produce a stasis of blood in 
the dependent portions of the lungs, and thus to maintain or increase 
the disease. Dr. West recommends, whenever the inflammation has 
reached an advanced stage, or involved a considerable extent of the 
lungs, that the patient be moved with great care and gentleness, lest, 
as he has often seen occur, convulsions be produced. 



AETICLE III. 



BRONCHITIS. 



Definition; Synonyms; Frequency; Forms. — The term bronchitis 
is now universally employed to express inflammation of the mucous 
membrane of the bronchia. 

It is usually called in this country catarrh, and catarrhal fever. It 
has been stated, under the head of Pneumonia, that many of the cases 
known amongst us by the poj^ular term catarrh-fever, are in fact, cases 



FREQUENCY — CAUSES. 197 

of pneumonia. We shall on account of this misapplication of names en- 
deavor to draw the distinction between bronchitis and pneumonia with 
great care. 

Since bronchitis and pneumonia have been more carefully distin- 
guished in the mortality returns of this cit}^, bronchitis is found to be 
the cause of a much smaller proportion of deaths than would have for- 
merly appeared. 

Thus, during the seven years ending with 1869, the total mortality 
from all causes (excluding still-born children) was, at all ages, 105,785 ; 
under fifteen years of age, 50,151 ; and under five years, 43,322. The 
mortality from bronchitis during this period was, at all ages, 969, or 
less than 1 per cent, of the entire mortality; under fifteen years, 509, 
or 1.01 per cent, of the mortality under that age; and under five years, 
495, or 1.14 per cent, of the mortality under that age. 

It is, however, one of the most frequent of the diseases of childhood, 
especially during the winter and early spring months. It is said to be 
more common as a secondary than as an idiopathic disease. Of 115 
cases observed by MM. Rilliet and Barthez, only 21 were idiopathic. 
Of 123 cases, however, that we have recorded, 76 were primary, and 
the remaining 47 secondary. The diseases during the course of which 
it is most apt to occur, are pertussis and measles. 

We shall describe three forms of the disease : 1, acute bronchitis of 
moderate severity; 2, acute suffocative bronchitis, or catarrh us suffoca- 
tivus, the congestive catarrhal fever described by Eberle and by Dr. 
Joseph Parrish, of this city; 3, subacute or chronic bronchitis. 

Causes. — Amongst the predisposing causes of the disease, age is one 
of the most important. MM. Eilliet and Barthez suppose it to be much 
more common in children over, than in those under five years of age. 
Of one hundred and fifteen cases observed by them, thirty-seven oc- 
curred between the ages of one and five years, and seventy-eight be^ 
tween six and fifteen years of age. It is scarcely fair, however, to 
compare a period of nine years with one of only four, as is done in the 
above statements. Of one hundred and twenty cases that we have 
seen in private practice, in which the age was noted, fifty-four occurred 
between birth and two years of age; thirty-nine between two and four 
years; twelve between four and six; six between six and ten; and 
three between ten and fifteen. Of eighty-one cases under four years 
of age, of which we have kept an accurate record, eleven occurred in 
the first half of the first year of life, twenty in the second half, mak- 
ing thirty-one for the first year; twenty-one occurred in the second 
year of life, nineteen in the third, and ten only in the fourth, showing 
that the liability it greatest in the first year of life, and particularly in 
the last half of that year, that it continues very strong in the second 
and third years, being nearly equal in each of these, and that it then 
suddenly diminishes. It would seem also that the simple acute, and 
the acute suffocative forms are most common under six years of age, 
while the secondary cases occur more frequently after that age. 

As to the influence of sex on the liability to the disease, it would ap- 



198 BRONCHITIS. 

pear from our experience to be rather more common in girls than 
boys, since of ninety-nine cases in which this point was noted, fifty- 
four occurred in girls and forty-five in boys. The fact of its being 
more frequently a secondary than a primary affection has already been 
noticed, though this has not been true of our experience. The diseases 
in which the largest number of cases occur are measles, pertussis, and 
typhoid fever. The secondary cases are most common, of course, dur- 
ing the prevalence of the diseases whose progress they complicate, 
whilst the primary cases are most common in the cold months of the 
year, and especially in the autumn and spring. The reader is referred 
to the table in the article on pneumonia for a full exhibition of the 
effects of season and temperature upon the frequency of this disease. 
Bronchitis is sometimes epidemic amongst children as it is amongst 
adults. It is important also to be aware that there is a strong ten- 
dency to attacks of bronchitis in rickety children. 

The only exciting causes whose effects in the production of the dis- 
ease seem clearly proved are sudden transitions from a warm into a 
cold atmosphere, and sometimes the contrary change; prolonged expo- 
sure to cold, particularly when combined with moisture; and the inspi- 
ration of irritating gases. We believe ourselves, from what we have 
seen in this city during the last thirty years, that the most fruitful 
cause of bronchitis, and also of pneumonia, croup and angina in early 
life, is the style of dress almost universally used for young children. 
The dress is entirely insufficient. It consists usually of a small flannel 
shirt, cut very low in the neck, scarcely covering the shoulders, and 
without sleeves;, of a flannel petticoat, a muslin petticoat, and an outer 
dress made in nearly ever}^ case of cotton. The dress, like the flannel 
shirt, is cut low in the neck, is without sleeves, and fits very loosely 
about the chest, so that not only are the whole neck, the shoulders, and 
the arms exposed to the air, but, in consequence of the looseness of the 
dress about the neck, it is fair to say that the upper half of the thorax 
is also without covering. In the infant, from birth to the age of six or 
eight months, the dress is made long, a wise provision so far as it goes, 
but from the time the skirts are shortened^ up to the age of four or five 
years in boys, when happily the time for boys' clothes arrives, and 
throughout childhood in girls the trunk of the body and the arms are 
dressed, or rather left undressed, as above described. But, not only 
are the neck, breast, and arms left bare, but in many children the 
greater part of the legs also is kept uncovered, or at least, short stock- 
ingS; scarcely rising above the ankles, and muslin or sometimes Canton 
flannel drawers, not reaching, or scarcely reaching to the knees, leave 
exposed to the air a large proportion of the cutaneous surface of the 
lower extremities. ISow, in this dress, the child passes the day in a 
house, the sitting-rooms of which are heated usually to 68° or 70°, but 
in which the entries, and sometimes the parlors, are frequently at a 
temperature of 60°, 50°, or even lower, as we ourselves have tested 
with the thermometer. And not only are the entries and parlors, and 
indeed all the rooms, saving the one or two in constant use, frequently 



EFFECT OF INSUFFICIENT CLOTHING — ANATOMICAL LESIONS. 199 

at the temperature just mentioned, but the air of the nursery itself is 
often allowedj through the negligence of the servants, and especially 
early in the morning, to foil to 60° or 58°, or possibly lower still. 

That this style of clothing is not correct, is proved by the simple 
focts that children who are dressed nearly the same in summer as in 
winter, suffer scarcely at all from colds in the summer season, when 
the thermometer seldom ranges below 76°, and is usually above that 
point; and also by the fact that adults have been driven by long and 
almost forgotten experience, to wear clothing twice or three times as 
warm as that which they put upon their children. How constantly 
do we see the strong and fully-developed man comfortably enveloped 
in a warm, long-sleeved flannel shirt, woollen or thick cotton drawers, 
and cloth pantaloons, vest, and coat, in the same room and in the same 
temperature with the little — often puny, pale, and half-naked — child. 
Eut it is almost impossible to make people understand that children 
need as much clothing as themselves. They always insist upon it that, 
as the child passes the greater part of the day in the house, it cannot 
require as much clothing as the adult who is obliged to go out and face 
the weather; forgetting, or refusing to see, that the former wears less 
than half, or probably not more than a fourth, as much covering as the 
latter, and that the adult, when in the house, and in the same rooms as 
the child finds his one-half or three-fourths warmer clothing not at all 
superabundant or oppressive. 

We have repeatedly had patients to get well of chronic catarrhal 
and laryngeal coughs, and to cease to have, as before, frequent recur- 
rences of these disorders, under the simple treatment of a long- 
sleeved and high-necked merino or flannel shirt; long woollen stock- 
ings, and stout Canton flannel drawers coming down below the knees; 
and that, too, after the most patient and assiduous, and sometimes over 
assiduous trials of drugs, diet, and confinement to the house, had en- 
tirely failed of any permanent good effects. The fact is, that though 
there are some few children who can bear the dress above-described 
without injury, there are a great many more who, while they wear it, 
either suffer all winter long from frequently repeated attacks of cold, 
in the shape of croup, chronic laryngeal irritation with cough, chronic 
pharyngitis, bronchitis, acute or chronic, or more rarely pneumonia; 
or, if they escape these direct effects, resulting from the constant and 
rapid waste of their caloric, they are rendered more pale, thin and deli- 
cate-looking than they would be were their vital forces husbanded by 
warm clothing, instead of being wasted in the constant struggle to 
keep up the heat of the uncovered body at the natural point. 

Anatomical Lesions. — We shall describe, first, the lesions met with 
in cases in which the disease is confined to the larger bronchia, the in- 
flammation not extending into the capillary tubes; and next, those ob- 
served in cases in which the disease has attacked the capillary bronchia. 
The former are those which constitute the form designated under the 
title of acute ordinary bronchitis of moderate severity, while the latter 



200 BRONCHITIS. 

are those to which the term capillary has been applied. Patients sel- 
dom die of the first-named variety of the disease alone, but as it often 
occurs as an accidental complication, or a more or less essential part of 
different severe and frequently fatal diseases, the morbid alterations 
which characterize it, have been very thoroughly studied and ascer- 
tained. 

The morbid alterations of acute ordinary bronchitis always exist in 
both lungs, and are confined to the larger bronchia, ceasing on a line 
with the smaller tubes and the capillary divisions. The most constant 
alteration is redness of the bronchial mucous membrane, caused by in- 
jection of the minute vessels of that and the subjacent tissues, and vaiy- 
ing in shade from a rosy to a bright-red or brownish tint. The mucous 
membrane is sometimes softened, a change which can be ascertained 
only in the largest tubes, and it sometimes presents a thickened, un- 
equal, and rough appearance. Ulcerations are very rare. The inflamed 
bronchia contain a more or less abundant viscid, transparent, or opaque 
yellowish mucus. 

In capillary bronchitis the alterations of the mucous membrane of the 
capillary tubes, do not always reveal the existence of the disease. That 
membrane is sometimes pale in the minute ramifications, and exhibits 
morbid changes only in those of medium size. The alterations of the 
membrane consist in redness, which is made up either of a number of 
fine points, seated in the membrane itself, or of arborizations seated 
both in the membrane and the cellular tissue beneath ; it sometimes 
presents a granulated appearance, and it may be more or less thickened, 
and its consistence diminished. The bronchia are usually filled and 
almost obliterated from the secondary divisions to the final ramifica- 
tions, by a substance of a yellowish-white or yellow color, non-aerated, 
and composed of a thick muco-pus. Portions of false membrane are 
sometimes, not as a rule, but exceptionally, found mixed with the secre- 
tions just described, while in other instances false membranes alone are 
present in certain tubes. The false membrane may exist in the form 
of patches, or it va&y constitute a lining to the whole extent of the 
bronchial ramifications. It is usually soft and but slightly adherent, 
and the mucous membrane beneath is either very pale and of its usual 
consistence, or red, softened, and rough. The different kinds of secre- 
tion are commonly most abundant in the bronchia of the inferior lobes. 

In a good many of the cases, another lesion, dilatation of the bronchia, 
is also found upon examination. This alteration evidently occurs under 
the influence of the inflammation ; it may affect either the length of the 
air-tubes, or only their extremities. In the former condition the tube 
continues of the same size, or becomes gradually larger from one of its 
early subdivisions, until it reaches the surface of the lung. In the latter 
condition a section of the lung presents an areolar appearance, from the 
presence of a multitude of little rounded cavities, communicating with 
each other and with the bronchia, of which they seem to be a continua- 
tion. These cavities are generally central, though they are sometimes 



ANATOMICAL LESIONS. 201 

foand upon the surface of the lung, in which case they are formed of 
the pleura, lined by the thinned membranes of the dilated bronchus. 

The fiict of these cavities being true dilatations of the bronchia, has 
been called in question by Dr. Gairdner {loc. cit., p. 76), who believes, 
on the contrary, '' that almost all the so-called bronchial dilatations, and 
all of those presenting the abrupt, sacculated character here alluded 
to, are in fact the result of ulceratice excavatioyis of the lung communi- 
cating with the bronchia." He supposes them to be the result of the 
expansion of certain small cavities, frequently met with in the bronchitis 
of children, and to be described directly under the title of vacuoles or 
bronchial abscesses, either by ulceration or by the act of inspiration. 

In addition to the lesions already described as existing in bronchitis, 
there is another one, not unfreqnently met with, to which we shall call 
attention, that to which the French writers apply the term vacuoles, and 
which Dr. Gairdner designates as bronchial abscess. The latter author 
states that in the centre of the collapsed lobules of a lung affected with 
acute bronchitis, there are found, not unfreqnently, small collections of 
pus, varying in size from that of a hemp-seed to double or treble that 
volume. " These small abscesses present, on section, an appearance so 
much like that of softening tubercles, as to be very readily mistaken 
by many persons for these bodies; and the resemblance is all the greater 
on account of the j^eculiar limited form of the condensation by which 
they are generally surrounded, which, when felt by the touch from the 
exterior of the lung, is exceedingly deceptive. In their interior, how- 
ever, these little abscesses contain, in the recent state, a very fluid pus; 
moreover, they are often met with as acute lesions produced by a few 
days of illness, and without a trace of tubercle in any other organ." 
When the pus is scraped or pressed out of these abscesses, in their re- 
cent form, they are found to be lined with a fine villous membrane, 
while in other instances they are not abruptly limited, but the pus ap- 
pears to lie in contact with the surrounding pulmonary tissue. The 
bronchia leading to the part of the lung thus affected, are found, when 
incised, to be much inflamed, their mucous membrane being vascular, 
thickened, and covered with pus; and some of them can be observed to 
communicate w^ith the purulent collections, the mucous membrane 
having been, at the point of communication, destroyed by ulceration, 
and either stopping short abruptly, or becoming gradually incorporated 
with the false membrane lining the abscess. Sometimes these abscesses 
or vacuoles communicate not only with the bronchia, but also with each 
other, without difficulty; sometimes, according to Dr. Gairdner, they 
break into one another and form more considerable excavations, but, 
more commonly, they remain of limited size, preserving perfectly the 
direction and relations of the bronchial tubes. They occur both in the 
diffused and lobular form of condensation from collapse of the lung, and 
both forms may sometimes be seen in the same lung. 

The alteration just now described has excited a good deal of discus- 
sion amongst medical writers, and has been very differently accounted 
for. MM. Eilliet and Barthez regard it as a simple terminal dilatation 



202 BRONCHITIS. 

of the bronchia, while MM. Barrier, and Legendre and Bailly, consider 
it to depend on a purulent breaking down of the vesicles of one or more 
lobules. MM. Hardy and Behier look upon it as a lesion of a complex 
nature, partaking both of dilatation of the bronchia and of puhnonary 
emphysema. Dr. Gairdner, as already mentioned, describes them as 
abscesses, and states that they "unquestionably arise from the accumu- 
lation of pus primarily in the extreme bronchial tubes of the collapsed 
lobules." This view, which is closely similar to that of MM. Barrier, 
and Legendre and Bailly, is, it appears to us, much the most reasona- 
ble that has been adduced. 

MM. Eilliet and Barthez, in their second edition, as has already been 
stated, in the article on post-natal collapse, describe at great length a 
state of congestion of the lung-tissue, as a most important element in 
the anatomical alterations of the bronchitic diseases. This congestion 
usually assumes one of two forms: it may be distinctly lobular, consist- 
ing then of disseminated patches, or^ as more generally happens, large 
numbers of contiguous lobules are affected, when it takes the form of 
generalized lobular congestion. These congested portions of the lung 
are almost always attended with more or less well-marked collapse of 
the vesicles, so that there is associated together the conditions of con- 
gestion and collapse. It is this combination of bronchitis, with conges- 
tion and collapse, which was formerly described by them, under the 
titles of lobular and generalized lobular pneumonia. The alteration to 
which the term carnification has been applied, and which not unfre- 
quently coexists with bronchitis, they regard as different from the 
above, and as consisting in a simple collapse of the lung-tissue, without 
the active or passive congestion which exists in the first form. The 
principal causes of this condition are, according to them, debility and 
catarrh. The signs of catarrhal inflammation are, they state, never 
scarcely absent. In only four out of thirty-one cases did they fail to 
discover them. 

The parenchyma of the lung presents, in bronchitis, different appear- 
ances in different cases. It is supple, crepitant, and of a rose-gray 
color, but does not collapse, especially the anterior portions, when the 
thorax is opened, as does healthy lung. This imperfect collapse depends 
either on the fact that the thick mucus and muco-pus which fill and ob- 
struct the bronchia, prevent the contained air from being expelled by 
the natural elasticity of the lung, or, when no secretions exist to pro- 
duce this effect, on the loss of the natural elasticity of the organ. An- 
other cause is the existence of vesicular emphj^sema, a lesion observed to 
a greater or less extent in nearly all the cases, and affecting usually the 
summit of the lung, its anterior edge, and also its posterior or lateral edge 
In a large number of cases, and particularly in those occurring in young 
children and in weakly and debilitated subjects of all ages, the tissue 
surrounding the diseased bronchia exhibits the condition which has 
already been fully described in the article on atelectasis, under the title 
of collapse of the lung. The extent and mode of distribution of this 
lesion, its peculiar and distinguishing characters^ its causes and mode of 



SYMPTOMS. 203 

production, and the method of treating it, have been carefully discussed 
in the article just referred to, and we shall make no further allusion to 
it, in this place, except to beg the reader, who is not already fully ac- 
quainted with it in all its bearings, not to suppose himself master of 
the subject of bronchitis until he has also fully studied that of collapse, 
as the two go together so constantly, and the latter is practically so 
important, especially in children, as to make it essential for him to 
understand both. 

The lesions just described as characteristic of acute bronchitis, are 
also met with in the chroiiic form of the disease. The dilatation of the 
air-tubes, however, presents different features. The calibre of the en- 
larged tube is often much greater, its walls are whitish and uneven, and 
cry under the scalpel, and beneath the mucous lining may be seen hy- 
pertrophied transverse fibres. The mucous membrane itself remains 
smooth and polished, while the tissues beneath are thickened and hy- 
pertrophied. 

Symptoms; Course of the Disease; Duration. — Acute simple bron- 
chitis exhibits very diiferent degrees of severity in different cases, being 
in some extremely mild and benign, and in others so much more severe, 
as to border closely on the capillary form of the disease. In its mildest 
form, it occasions merely slight cough and stuffing, a little mucous rale 
over the larger bronchia, with a total absence of dyspnoea, or of decided 
fever. In cases rather more severe than this, it begins with a moder- 
ately frequent cough, which, dry at first, soon becomes loose, and is 
neither paroxysmal nor painful. The expression of the face remains 
natural, with the exception of an appearance of slight languor. The 
pulse and respiration are but slightly accelerated; the external phe- 
nomena of the latter, an important means of diagnosis in infants, re- 
main natural ; it occurs without jerking, the rhythm continues even and 
regular, and there is no violent action of the alse nasi. The percussion 
is not modified. Auscultation reveals in very young children a mixture 
of mucous and sibilant rales on both sides, which come and go, and are 
of short duration ; in older children, the moist rales predominate, and 
commonly last several days. These sounds are seated in the larger 
bronchia. The temper of the child is not much changed; the appetite 
is not entirely lost ; there is neither vomiting nor diarrhoea; and the 
fever is usually slight. The disease remains nearly stationary, or in- 
creases for a variable length of time, after which the cough becomes 
looser, and in children over five years of age, is sometimes attended 
with expectoration of frothy or yellowish mucous sputa, whilst under 
that age there is no expectoration. The fever and other symptoms, 
with the exception of the cough, now subside; the cough remains some 
daj's longer. 

In attacks still more severe than this, the symptoms resemble very 
much those just now described, but they are all more intense. The 
cough is tighter, more frequent, harassing, and especially it is more 
painful, as shown by the fact that the child cries and complains, and 
that a marked expression of pain passes over the face at the instant of 



204 BRONCHITIS. 

coughing. There is more fever, the skin being hot and dry, and the 
pulse more frequent, rising often to 130 or 140, and in one case to 156. 
The respiration is hurried, and though not attended with the same 
labor and anxiety as in the capillary variety, it is evidently oppressed; 
it counted in three cases, 60, 60, and 62. The temperature is consider- 
ably elevated, but not so much so as in pneumonia, rarel}^ rising- 
above 102° or 102.5°. There is more restlessness, fretfulness, and gen- 
eral distress; the appetite is greatly diminished or lost, and infants 
nurse with less avidity than usual, or refuse to nurse at all for several 
hours together. In cases of this kind, the phj^sical signs are more de- 
cided than in those of milder degree, there being a greater abundance 
of mucous and dry rales, and generally some subcrepitant rale, and 
they are heard over a larger extent of surface, usually over the lower 
half, two-thirds, or even the whole dorsum of the chest. The symp- 
toms are almost always most marked and severe in the after-part of 
the day and night. Yery often the patient will be comparative!}" easy 
and comfortable in the morning, but as the day goes on, he becomes 
more feverish, restless^ and fretful; the cough grows more troublesome, 
more frequent, and tighter; the breathing is quicker and more oppressed ; 
the face is more flushed; the sleep is broken and disturbed, and the 
child may appear through the night quite ill ; and yet as morning ap- 
proaches, the symptoms moderate, the skin often softens and becomes 
moist, and the whole aspect of the case shows a great amelioration in 
the manifestations of the disease. 

According to Handfield Jones, this almost invariable tendency to 
aggravation of catarrhal disorders during the night is due to a lower- 
ing of the nerve-power, the vaso-motor nerves partaking of the general 
debility, and thus allowing dilatation of the arteries, and causing in- 
creased hj^persemia of the aflPected parts with more abundant exu- 
dation. 

The duration of this form of bronchitis is very uncertain; the idio- 
pathic cases last usually from four to seven or eight daj^s, though they 
may last from sixteen to twenty-five; the duration of the secondary 
cases depends, in great measure, on the nature of the diseases during 
which they occur. 

In any of these different degrees of acute simple bronchitis, the patient 
is liable, especially if it be a weak and debilitated child, or a young in- 
fant, to sudden and alarming aggravations of the symptoms. The 
breathing becomes suddenly either greatly increased in frequency, or 
excessively labored and oppressed, the surface becomes pale, the ex- 
pression dull and languid, or distressed, the child is drowsy and inat- 
tentive, or uneas}' and restless, the hands and feet are coolish^ the act 
of sucking is performed with diflSculty, or the child refuses the breast 
entirely, and it is evident that, from some sudden change in the condi- 
tion of the lungs, the act of respiration and the aeration of the blood 
are very seriously interfered with. If this sudden aggravation of the 
symptoms be unattended with a corresponding increase of the febrile 
phenomena, as marked by greater heat of skin and augmented action of 



SYMPTOMS OF CAPILLARY BRONCHITIS. 205 

the circulation, it is altogether probable that it depends on a collapse 
of larger or smaller portions of the pulmonary texture, and if, on ex- 
amination, we discover dulness on percussion, distant bronchial respi- 
ration, and cessation or greatly diminished abundance of the bronchitic 
rales, over parts of the chest where a few hours or a day before there 
had existed all the physical signs of bronchitis, there can be no longer 
any doubt as to the cause of the suddenly increased severity of the 
symptoms, — it must be owing to collapse. 

Acute svfocative bronchitis, or capillary bronchitis, may succeed to the 
form just described, or appear as an idiopathic affection. Under either 
condition the general symptoms are more threatening than in the preced- 
ing form, and the disease soon assumes all the appearances of great sever- 
ity. The child is very uneasy and restless, constantly changing its posi- 
tion, moving about in the crib or bed, or insisting upon being changed 
from the bed to the lap, or from the lap to the bed. In one case that 
came under our charge the oppression was very great, and the only posi- 
tion in which the child was at all satisfied was resting on the mother's 
arms, with the front of its chest applied against her breast, and the 
head hanging over her shoulder. The expression of the face is anxious 
and disturbed, and its color usually pale or slightly bluish. The temper 
is irritable or subdued; the child hates to be disturbed, and generally 
chooses its own position. The respiration is very much accelerated, 
running up in a very short time to 60, 70, or 80, and is usually more 
or less irregular, and evidently laborious and difficult. The cough is 
very frequent, troublesome, and evidently painful; it occurs in short 
paroxysms usuall}^. with or without stridulous sound, is at first dry, 
and after a few days is accompanied, in older children, by whitish or 
yellowish expectoration. In some instances, the sputa consist of mucus 
tinged with blood, or of pure blood even, and still more rarelj^ of mucus 
mingled with small shreds of false membrane. The appetite is entirely 
lost; the tongue is usually moist and furred white; there is acute thirst, 
and yet, in severe cases, though the presence of acute thirst is evident 
from the manner of the child, only very small quantities of water are 
taken, from the impossibility of suspending the respiration long enough 
to allow of more being swallowed; the drink is gulped rapidly, sud- 
denly, and with great difficulty, and after a time is refused almost 
entirely from this cause. In children old enough to talk, the speech is 
short and abrupt; the patient dislikes to speak, from the fact that the 
efi'ort obliges him to suspend momentarily the act of breathing. Fever 
sets in from an early period; the skin is hot and dry, and the face is 
flushed at first, though it soon becomes pale in most cases, from the 
approach of an asphyctic state. The pulse becomes frecpient, rising 
soon after the onset to 130, 140, 150, or higher; it is full and hard earh^ 
in the attack. The resonance on percussion is not modified. Auscul- 
tation reveals at first sibilant rale mixed with some mucous rales; 
but soon a fine subcrepitant rale is heard over all the lower parts of 
both lungs behind, and approaching sometimes, over the bases of the 



206 CHROXIC BRONCHITIS. 

lungs, the character of crepitus. After a time the subcrepitant rale is 
beard over the whole, or nearly the whole dorsum of the chest, and to 
a greater or less extent, though not so well marked as behind, over the 
anterior regions of the thorax. This rale is audible at first both in 
inspiration and expiration, and is very distinct, but at a later period, it 
is heard only in the inspiration, or there is substituted for it a mucous 
rale, while the subcrepitant rale is now heard only in the forced inspira- 
tions during coughing or crying. These rales are fugitive and irregular, 
disappearing or changing from one to the other after fits of coughing. 

Should the case not take a favorable turn, which change would be 
indicated by a moderation in the symptoms just detailed, and especi- 
ally by easier and fuller res2:>iration, with diminution of the amount of 
the subcrepitant rale, and return of the natural respiratory murmur 
over some parts of the chest, the symptoms look still more alarming. 
The oppression becomes excessive; fits of dyspnoea occur, in which the 
child is extremely restless and distressed, tossing itself about on the 
bed ; the respiration runs up to 80. 90, or more, in the minute, and is 
attended with violent action of the alse nasi ; the pulse grows more and 
more frequent, rising to 150 or 180, and it loses force and volume; and 
the fiice assumes a whitish or slightly bluish tint, looks puflFed, and is 
sometimes covered with perspiration. As the fatal termination ap- 
proaches more nearly, the pulse becomes small, thready, and irregular; 
the respiration is uneven, irregular, stertorous, and often slower than 
before; the cough is smothered and less frequent; the restlessness gen- 
erally diminishes, and the child sinks into quiet, and often becomes 
comatose: the paroxysms of suffocation are less frequently renewed, 
and less violent, and death occurs in a state of quiet insensibility, or is 
preceded by partial or general convulsive movements. 

The duration of this form may be stated to be, on the average, be- 
tween five and eight days. It may, however, end fatally in a much 
shorter time. In an example that we saw, in a child four months and 
a half old, death occurred in twenty-six hours from the onset. Dr. 
Eberle states that it seldom lasts longer than two or three days, and 
that in very young infants death sometimes occurs on the first day. 
M. Bouchut gives us the duration in children at the breast, from two 
days to a week. Dr. West mentions a case that proved fatal in less 
than forty-eight hours. In the favorable cases that we have seen the 
duration was seven, eight, and ten days. 

Subacute and chronic bronchitis generally follows one of the acute 
forms of the disease. The character and severity of the symptoms 
vary very much in diff'erent cases. "We have known some children to 
present for several months together, in the winter season, slight bron- 
chitic symptoms, consisting in wheezing and somewhat accelerated 
breathing; cough, more or less frequent; occasional feverishness, espe- 
cially at night; some diminution of appetite and loss of flesh; and sibi- 
lant and sonorous with mucous rales, heard here and there, but still 
without severe symptoms during the greater part of the time. Chil- 
dren laboring under this kind of bronchitic irritation are liable to, and 



SYMPTOMS. 207 

generally have, from time to time, more or less sharp attacks of acute 
bronchitis, in which they present the usual symptoms of that form of 
the disease. These attacks are very apt to occur coincidently with 
changes in the weather, and in some patients the liability to them is 
so great, from the excessive susceptibility of the system to the weather, 
that no care will prevent them. In some instances, we are very sure 
that an aggravation of the symptoms of the chronic form constantly 
occurs whenever the child is about cutting additional teeth, whilst in 
the intervals between the appearance of the successive teeth, the child 
remains comparatively well. ^Ye believe that the cause of the aggra- 
vation, at the moment of cutting the teeth, is to be looked for, not only 
in the act of dentition itself, but in the circumstance that the liability to 
cold is greatly increased at that particular moment, probably because 
the forces of the system are so weakened by the effort of the dentition 
as to lessen the power of resistance against the disturbing influence of 
a changing, and particularlj- of a falling temperature. 

Cases of the mild kind of chronic bronchitis that we have just been 
describing, usually get well under proper medical, and especially under 
proper hygienic means, after several weeks or two or three months; 
while in other instances the disorder continues, in spite of every pre- 
caution, throughout the winter and spring, and only ceases as the warm 
summer months arrive. We have known the same disposition to show 
itself again in the following winter. In other instances again, the fre- 
quent attacks of severe bronchitis, together with the effect of a con- 
stant slight bronchitic inflammation, ends in the production of an em- 
physematous state of parts of the lung, and the child exhibits more or 
less marked asthmatic symptoms, which show themselves whenever a 
slight increase of the bronchitis occurs, and whenever the digestive sys- 
tem is deranged by imprudence in diet or other causes. It is particu- 
larly in such cases as these that the bronchial affection is apt to be 
associated with rickets, and we should, therefore, always carefully 
search for the evidences of this latter disease. 

In other examples of chronic bronchitis the symptoms are much 
more severe. These cases almost always follow an acute attack of the 
disease. The frequency of the respiration and the attacks of dyspnoea 
persist; the cough is loose and paroxysmal, and the pulse frequent and 
small; evening exacerbations of fever take place, and the face and 
sometimes the rest of the surface are often covered with perspira- 
tion. Auscultation reveals tubal blowing, with mucous or loud sonor- 
ous rales, which seem to indicate the presence of dilatation of the 
bronchia. Emaciation makes rapid progress, the face is pale and 
blanched, the eyes sunken, the nostrils are covered with mucous or 
bloody crusts, and the lips ulcerated. Strength diminishes progres- 
sively; the appetite is lost, and the thirst acute; colliquative diarrhoea 
appears; and after twenty, forty, or more days, the child perishes in 
the last stage of marasmus. This form of bronchitis often simulates 
phthisis very closely, and may last for a long time, even several years. 



208 CHRONIC BRONCHITIS. 

It rarely occurs under the age of five years. The expectoration con- 
sists of purulent or pseudo-membranous secretions in variable quantity. 

Particular Symptoms — Physical Signs. — The dry rales are amongst 
the most frequent alterations of the respiratory sound in bronchitis. 
They may be sibilant or sonorous; they seldom exist alone, but are ac- 
companied with mucous rales, and diminish as the latter become more 
abundant. As the dry rales cease to be heard, they are replaced by 
mucous or suberepitant rales, or by feebleness of the respiratory^ mur- 
mur. The sibilant rale is often heard over the whole thorax, though 
it may be confined to the posterior portions. It is not restricted to 
cases of inflammation of the larger bronchia only, but is also present 
in capillary bronchitis. 

Moist Bales. — Mucous and suberepitant rales do not exist in all cases 
without exception, as they may be absent in such as are very mild. 
They may generally be heard over both sides behind, more rarely over 
the whole of the chest, and almost always both in inspiration and ex- 
piration. They are generally persistent, but are sometimes suspended 
for a moment and replaced by sibilant rale or feeble resj^iratory sound. 
Their duration is in proportion to that of the disease. 

Feeble respiratory murmur is sometimes observed. It is not perma- 
nent, occurs during the interruptions of the suberepitant or sonorous 
rale, and does not occupy the whole extent of the thorax, but is limited; 
it is intermittent, and is not accompanied by diminished resonance. 

AVhen dilatation of the bronchia exists to a considei-able extent it 
gives rise to bronchial or even cavernous respiration, and to bronchial 
resonance of the voice, cry, and cough. The bronchial respiration dif- 
fers from that of pneumonia by its tone, and by its intermitting char- 
acter. The percussion is generally sonorous. 

It has alread}^ been stated in the account of the symptoms that it 
happens not unfrequently in severe bronchitis, and also in mild bron- 
chitis occurring in debilitated children, that the respiratory sound sud- 
denly becomes feeble, or even entirely suppressed, over parts of the lung, 
while in other instances a distant and imperfectly marked bronchial 
respiration takes the place of the natural vesicular murmur. These 
changes are heard either over small disseminated points of the lung, or 
over large surfaces; they are associated with more or less evident dul- 
ness on percussion, and what particularly characterizes them, the}' are 
very fugitive, being present at one examination, and absent perhaps at 
the next. The appearance of these changes in the phenomena afforded 
by auscultation, was formerly thought to indicate the occurrence of 
pneumonia, and especiallj' of lobular pneumonia; they are now much 
more satisfactorily explained by the supposition that they depend on 
diffused or lobular collapse of the tissue of the lungs. 

The phj^sical signs above described are not invariably present in 
bronchitis. Cases do occur, though they are very rare, in which aus- 
cultation fails to reveal the characteristic signs of the disease. 

Eational Symptoms. — The rational symptoms are of the utmost im- 
portance in informing us of the degree of severity of the attack. 



RATIONAL SYMPTOMS. 209 

Cough generally exists from the beginning, being in mild cases more 
or less frequent, and either dry or loose, while in severe cases it is fre- 
quent or very frequent, at first dry and then moist, and very rarely 
hoarse. In acute capillary bronchitis, the cough has a peculiar charac- 
ter. From the first day it occurs in short paroxysms, lasting from a 
quarter to half a minute. The paroxysms varj^ greatly in violence, 
occur at irregular intervals, and generally continue without interrup- 
tion to the fatal termination, though they are sometimes replaced by 
simple loose cough a few days before that event. The cough is rarely 
painful, so long as the inflammation remains simple. Expectoration is 
never present in very young children. When it occurs in those over 
five years of age, it consists, in the mild form, of a sero-mucous or of a 
frothy and yellowish mucous liquid. In general bronchitis it is sero- 
mucous at first, becoming after a few days yellowish and more or less 
viscous; it is sometimes nummular and sometimes amorphous. 

In the capillary form, as already mentioned, the sputa consist of 
mucus tinged with blood, or of pure blood even, and in some rare cases 
there are mixed with the mucus, shreds of false membrane, which may 
present the form of casts of the minute ramifications of the bronchial 
tubes. 

The respiration varies in its characters according to the extent and 
violence of the disease. In mild cases, it is not much increased in fre- 
quency, being generally between 28 and 40 in the minute. In more 
violent cases, and particularly when the disease implicates the smaller 
bronchia, it becomes very frequent. The acceleration is slight in the 
beginning, but increases regularly as the case progresses; thus it may 
be 30 at first, and rise afterwards to 50, 60, 80, and even 90. When 
not very much quickened, it remains even and regular; when more so, 
it becomes somewhat laborious, and the movements of the chest are full 
and ample; in severe cases, attended with much dyspnoea, it is often 
irregular, or assumes the characters to which M. Bouchut has applied 
the term expiratory, that is, the order of the movements is inverted, 
each respiration beginning with the expiration, leaving a pause be- 
tween the inspiration and expiration, instead of between the expiration 
and inspiration. In chronic bronchitis with copious purulent or pseudo- 
membranous expectoration, the dyspnoea is generally habitual. 

Fever. — The fever is slight in mild cases, the pulse rising very little 
above its natural standard. The heat is not great, and the febrile move- 
ment usually subsides before the termination of the disease. In the 
grave or capillary form, on the contrary, the pulse is always frequent, 
and continues to increase in rapidity as the disease advances. It varies 
between 104, 120, 160, and in very violent cases, rises as high as 200. 
Early in the attack, it is vibrating, rather full and regular, whilst in 
fatal cases, it always becomes small, irregular, trembling, and unequal. 
The skin is generally hot in proportion to the activity of the pulse, ex- 
cept towards the termination, when the extremities often become cool. 
The temperature does not rise so rapidly nor reach so high a point as 
in pneumonia. Thus Koger gives as the highest temperature observed 

14 



210 BRONCHITIS. 

by himself in bronchitis 102.2°; while the average in his cases of the 
acute febrile form was 100.9°. The skin is almost always dry. In very 
young children it is often pale and cold, and covered with perspiration 
from the beginning. 

The expression of the face is unchanged in mild cases, but when the 
disease is violent and extensive, becomes deeply altered after a few 
days. The eyes are then surrounded by bluish rings, and the expression 
is uneasy, anxious, and sometimes, but less frequently, exhibits an ap- 
pearance of profound exhaustion. The anxiety of the countenance in- 
creases with the oppression ; the alse nasi are dilated, the nostrils dry 
or incrusted, and the lips and face, which are extremely pale or momen- 
tarily congested, assume a purple tint, particularly after the paroxysms 
of cough. 

The decubitus is indifferent at first, but as the disease progresses, the 
child lies with its thorax more or less elevated, or is restless and con- 
stantly changing its position. 

In dangerous cases there is great distress and restlessness after the 
first few days, or even from the beginning. In some instances the ir- 
ritability and peevishness are excessive and uncontrollable, while in 
others there is heaviness and somnolence, especially towards the termi- 
nation of fatal cases. Some of the disorders of the nervous system just 
mentioned are present in all the grave cases. 

Digestive Organs. — There is moderate ?^/u>s?^ and incomplete anorexia 
when the disease is mild, but, when severe, the thirst is generally acute, 
and the appetite entirely lost. The state of the bowels varies. The 
tongue and abdomen present no special characters in idio2>athic cases. 

Urine. — The great majorit}^ of recorded observations of the condition 
of this excretion in bronchitis, relate to the disease as occurring in the 
adult. The following summary is taken from Parkes : the condition 
of the urine in bronchitis varies greatly with the grade of the disease ; 
in the grave forms, it resembles that of pneumonia, the urea being in- 
creased, and the chloride of sodium at times entirely absent. The urine 
has also been quite frequently found to be temporarily albuminous in 
such cases. 

Diagnosis. — The mild form of bronchitis, in which the inflammation 
is confined to the larger bronchia, is not likely to be mistaken for any- 
thing but the early stage of hooping-cough. The diagnosis can be made 
only by attention to the different characters of the cough, which is more 
spasmodic and paroxysmal in pertussis, by the absence of fever in that 
disease, and by the development of the j^eculiar symptoms of each, as 
the case progresses. The diagnosis between bronchitis and pneumonia 
is seldom difficult, except when the latter is grafted upon the former, 
or in cases of ptirtial pneumonia, attended with bronchitis. In well- 
marked cases of the two diseases, there can be no difficulty. The re- 
striction of the physical signs to one side alone of the chest in pneumo- 
nia, the peculiar crepitus of that disease, or when this is not heard, the 
fineness of the subcrepitant rale, limited to the upper or lower regions 
of one lung, the bronchial respiration and bronchophony, the dulness 



DIAGNOSIS. 211 

on percussion over the seat of disease, the greater sharpness and sever- 
ity and the different location of the pain, the more acute character of 
the fehrile reaction, as marked by the pulse, skin, and thirst, the more 
abrupt and higher elevation of temperature, and the kind of expectora- 
tion, when there is any, will always enable us to distinguish the two 
with almost absolute certainty. In cases, however, in which the two 
are combined, the diagnosis is not so easy, but even here the presence 
of dulness on percussion, and of crepitant or fine sttbcre23itant rale, or, 
when these are absent, of pure metallic bronchial respiration with bron- 
chophony, over limited portions of the lung, will generally render the 
matter clear. 

The sudden supervention of dulness on percussion over large j^ortions 
of one of the lobes of a lung, or over disseminated patches, with feeble 
or absent respiratory sound, or with muffled and distant bronchial res- 
piration, generally indicates the occurrence of collapse in the part of 
the lung over which these signs exist ; and when these symptoms show 
themselves without any increase in the severity of the febrile reaction, 
but rather with a diminution, there is every reason to suj^pose that 
they depend, not upon inflammatory condensation of the parenchyma 
of the lung, but upon simple collapse, from the presence of obstructive 
secretions in the bronchia. 

Dr. Gairdner (loc. cit., p. 6) has called attention to a difference in the 
character of the dyspnoea in the two diseases, which is, we think, of 
considerable importance, and which we have often remarked ourselves. 
In bronchitis, of any considerable severity, the respiration is always 
evidently labored ; it is performed only with the aid of all the accessory 
muscles of respiration, and in really severe cases it is extremely labori- 
ous, the inspiration being long-drawn, exhausting, and inadequate. The 
dyspnoea of pure pneumonia is, on the other hand, quite different. It 
is merely an " acceleration of the respiration, without any of the heaving 
or straining inspiration observed in bronchitis, or in cases where the 
two diseases are combined." Dr. Gairdner states that he has repeat- 
edly seen patients affected with a great extent of pneumonia of both 
lungs, in whom the extreme lividity and rapid respiration, numbering 
fifty or sixty in the minute, showed infallibly the amount to which the 
function of the lung was interfered with, who, nevertheless, lay quietly 
in bed, breathing without any of the violent effort, or disposition to as- 
sume the erect posture, so constantly accompanying the more danger- 
ous forms of bronchitis. In children these differences are even more 
marked than in adults. 

Chronic bronchitis may be mistaken for tuberculosis of the lungs or 
of the bronchial glands. The distinction can be made only by careful 
study of the history of the case, and of the phenomena afforded by aus- 
cultation and percussion, which are detailed in our article on tubercu- 
losis. 

It is also important that we should not overlook the evidences of 
rachitis, which, as before stated, yqyj often exist in children who are 
predisposed to attacks of bronchitis. 



212 BRONCHITIS. 

Prognosis. — Bronchitis is rarely a fatal disease, so long as it remains 
confined to the larger bronchia, constituting the acute simple form, of 
moderate severity. Capillary bronchitis is, on the contrary, a very 
dangerous affection at all times and at all ages. Even ordinary, simple 
bronchitis, however, may prove fatal in young infants, and in debilita- 
ted children of all ages, from the supervention of collapse of portions 
of the pulmonary tissue; and it is necessary, therefore, that the prog- 
nosis given should always be guarded, when the disease occurs under 
either of these two conditions. The prognosis differs also in the pri- 
mary and secondary forms of the disease, since, as might be expected, 
the danger is much greater in the latter than in the former variety. 

We have met with a large number of cases of bronchitis, out of which 
we have kept more or less copious notes of 123. Of these, 108 were 
mild, and 15 capillary. Of the 108 mild cases, 65 were primary, all of 
which recovered; and 43 secondary, of which 2 died. Of the 15 capil- 
lary cases, 11 were primary, of which one died, and four secondary, of 
which 2 died. Of the whole number, 123 in all, 5 proved fatal. The 
danger from the disease depends very much also upon the hygienic 
conditions in which the patients are placed. In hospitals and amongst 
the poor it is much more dangerous than in private practice amongst 
the easy classes of society. This is shown by the fact that all the cases 
of the capillary form observed by MM. Eilliet and Barthez and Fauvel, 
in hospital practice, proved fatal, while of 15 cases seen by ourselves, 
in private practice, under the most favorable hygienic conditions, only 
3 died. 

The symptoms indicating great danger are, increase of the dyspnoea, 
extreme anxiety, small and irregular pulse, coolness or coldness of the 
skin with clammy sweats, much jactitation, and delirium, drowsiness, 
or coma. With such symptoms the danger is greater and the fatal ter- 
mination more imminent in proportion as the child is younger, less ro- 
bust, and its constitution exhausted by preceding or coincident disease. 

Treatment. — The acute simple form of bronchitis is frequently so 
mild as to need no other treatment than careful attention to the hygi- 
enic condition^ of the patient, and the administration of some simple feb- 
rifuge and expectorant. The child ought to be confined to one room, 
in a mild and uniform temperature, and should be kept quiet until the 
development of the symptoms shows what is to be the type of the at- 
tack. The degree of repose of the body necessary will depend on the 
presence or absence of fever. We believe that the practice of keeping 
the bod}^ quiet in all febrile disorders, is one of the most important 
therapeutic means we have. It is long since one of us, having seen his 
father insist upon putting children to bed for a feverish cold, began to 
follow the same practice. Time and experience have made even more 
clear to us the wisdom of the practice, especially in regard to very 
young children. 

So soon as the attack of bronchitis becomes severe enough to cause 
fever, whether the fever be continuous or occur only in the afternoon 
and night, the patient ought to be confined to the lap or bed. Suckling 



TREATMENT. 213 

children, and those under three yeurs of age, must be allowed to lie on 
the lap at times, hut even they maybe taught, very early, to rest quietly 
in the crib the greater part of the twenty-four hours. Children over 
three years old can almost always be taught to staj^ in their beds by a 
little management and authority, if only the parent is resolute. If not 
very sick, they should have a large pillow put up against the head of 
the crib or bed, and against this they should be placed in a sitting pos- 
ture, with the bedclothes arranged over the lap; and, in cool or cold 
weather, with a light flannel sack over the night-dress. Here they 
ought to be kept all day, allowed to change their position as they wish, 
and the}^ should be kept as cheerfal and happy as possible with toys, 
books, pictures, readings, tale-telling, or what not. Under such circum- 
stances, a new and interesting toy will often do more good by far than 
any drug in the materia medica. We have often been surprised, and 
delighted, too, to find a bronchitis which had been hanging over a 
young child for several days or a week, getting gradually worse, day 
by day, under the trotting-about S3\stem, begin to mend from the day 
the child was put to bed, and disappear in two or three daj^s, and that, 
too, without any change in the other remedies. 

The clothing ought to be warm, and yet not sufficient to produce free 
perspirtition, as this, by sudden exposure and evaporation, often induces 
chilliness. The diet must be simple, and may consist of anj^of the milk 
prej)arations, with or without bread, or bread and butter. Light soups 
in the middle of the day, or roast potatoes or apples, with bread, may 
generally be allowed. 

As for medicines, in this mild form they are of comparatively little 
consequence, if the above measures be carried out. In the after-part 
of the day, when fever sets in, we may prescribe a febrifuge of citrate 
of potash, such as the following, for children of two to four years old : 

K- — Potass. Citrat., . . . . • 3J- 

Syrup. Ipecac, f^j vel ^^^ij. 

Tr. Opii Caraph., f^j vel ^ij. 

Syrup. Simp., f^ss. 

AqujB, nd f^iij.— M. 

A teaspoonful every two or three hours. 

This should be given until the child sleeps, and occasionally in the 
night if there be cough and restlessness. At six months of age, the 
following may be used in the same manner: 

R. — Syrup. Ipecac., 

Tr. Opii Camph., aa . . . . f^ss. 

Spts. ^ther. Nitros., vel 

Liq. Ammon. Acetat., .... f:^ij. 

Syrup. Simp., fgv. 

Aquae, f^ij.— M. 

Give a teaspoonful every two hours. 

If the fever is very slight, and the cough only moderately severe, it 
is often well to use no drug through the day, but to give in the even- 



214 BRONCHITIS. 

ing, twp hours before bedtime, and again at bedtime, some simple ex- 
pectorant and anodyne. Thus at two or three months of age, three to 
five drops of syrup of ipecacuanha with five of paregoric, or half a drop 
to a drop of laudanum ; at one or two years, ten drops of the syrup with 
ten to twenty of paregoric, or two of laudanum; at five to ten ^^ears, 
ten to twenty drops of the syrup, with twenty to thirty of paregoric or 
five of laudanum. The laudanum is often better than paregoric, as it 
produces a more decided and lasting impression on the nervous system, 
and appears to extend its useful control over the sjauptoms further into 
the following day. 

In this verj^ mild form there is no necessity for giving active purga- 
tives. If the bowels are moved once in the day, or once in two days, 
it is best not to interfere with them. If, however, the patient be con- 
stipated, a little simple syrup of rhubarb, a teaspoonful of castor oil, or 
an enema, will be quite sufficient. A warm foot-bath, in the evening, 
containing salt, or, better, mustard, will often assist in moderating the 
cough and promoting quiet sleep. 

When, in this acute form, the symptoms assume greater severity, 
when signs of reaction are prominent, the dyspnoea considerable, and 
the cough frequent and harassing, it was formerly quite the custom to 
emplo}^ depletion. In a former edition of this work, it was stated that 
the abstraction of a few ounces of blood by leeching or cupping, was 
allowable under these circumstances, but that a large majority of such 
cases would do perfectly" well without bloodletting of any kind. We 
now believe that such practice is unnecessary in any of this class of 
cases. Attention to hygienic measures is, however, even more impor- 
tant than in the milder cases. Confinement to the bed ought to be a 
positive rule in such cases. If the bowels are not freely moved, a dose 
of castor oil, rhubarb, or magnesia should be given, and the patient 
then put upon the use of one of the febrifuge mixtures recommended 
above. When the fever is very high, and the patient over a year old, 
antimonial wine may be substituted, with advantage, for the syrup of 
ipecacuanha. 

If, as the case progresses, the bronchial secretions become very 
abundant and the dysj^noea severe, the proper remedy is an emetic. 
This may be ipecacuanha, either in powder or syrup, or a teaspoonful 
of powdered alum, to be repeated if necessary, in tenor fifteen minutes. 
The latter substance is, as we have stated under the head of croup, a 
ver}^ certain, efficient, and safe emetic. 

Great benefit may be obtained in all forms of bronchitis, from the 
more or less, frequent application of mustard poultices to the front or 
back of the thorax, and from mustard foot-baths. 

The mercurial preparations, so much recommended by many of the 
English and by some of our own writers, are, in our opinion, very 
seldom, if ever, necessary in this, or indeed, in any of the forms of 
bronchitis in children. 

MM. Eilliet and Barthez recommend, when the cough and sibilant 
rale persist after the disappearance of the febrile symptoms, the use of 



TREATMENT. 215 

small doses of the flowers of siilpbiir. We have ourselves known this 
remedy to prove of service in sneh cases. About four grains may be 
oriven every three hours to a child four years old. 

The treatment of the grave acute or capillary form of this disease 
brings up again the question of bloodletting. We, like all the rest of 
the world, have abandoned the practice as a rule, but we think that 
when, in a case of the kind now under consideration, the age being 
over two years, the oppression is very great, the right heart laboring, 
as shown by a congested surface and a throbbing cardiac impulse at the 
base and left edge of the sternum, and the strength not too much re- 
duced, the abstraction of from two to four ounces of blood from the in- 
terscapular space by cups or leeches, would be a useful and legitimate 
practice. We venture to give this advice from our own past experience, 
and from the views taught quite lately as to the effect and value of de- 
pletion in relieving the overdistended right heart, produced by an ob- 
stacle to the pulmonic circulation. 

There is no occasion for repeating here w^hat has been said, under 
the head of pneumonia, in regard to tartar emetic. But if the temper- 
ature be very high, and the pulse full and strong, we believe that the 
small doses of sulphurated antimony (gr. J^) w^e then recommended, in 
combination with Dover's powder, every two or three hours, are very 
useful in moderating the inflammatory symptoms. Should this be fol- 
lowed by nausea or vomiting with exhaustion, they must be suspended at 
once. The physician, and especially the young and inexperienced one, 
ought to know that the susceptibility to the action of all antimonialsis 
singularly different in different individuals. We have seen a heartj^ 
adult woman thrown into a most violent, and for a time alarming chol- 
eraic condition^ by two doses of yVth of a grain of tartar emetic each. 
We saw once a fine hearty boy five years of age, vomit violently, grow 
pale, weak, and faint away, from two teaspoonfuls of the mel. scillse 
compositum, containing in the ^wo doses, the fourth of a grain of tartar 
emetic. And even twelfths of a grain of the sulphurated antimony will 
sometimes cause a degree of nausea and prostration in young children 
which ought not to be kept up, though w^e never saw it occasion such 
effects as those just mentioned as following the use of tartar emetic. 
When, therefore, the sulphurated antimony acts with any undue vio- 
lence, it ought to be stopped, and we should substitute the citrate of 
potash mixture proposed for the mild form of bronchitis. 

In connection with one of these internal remedies, counter-irritation 
to the surface of the chest will be found of very great service. Indeed, 
we doubt very much whether it is not the most important part of the 
treatment. It may be obtained by applications of dry cups to the back 
of the chest, or if this be inconvenient or objected to for any cause, by 
the use of mustard poultices. The poultice ought to be about the size of 
the hand, or one-half larger, and it should be made of one part mustard 
to two of Indian meal or flour. It is to be mixed with w^arm water, cov- 
ered with book muslin or cambric, and applied first to the dorsum of 
the chest; after having reddened at that point, it should be shifted to 



216 BRONCHITIS. 

the front of the thorax. The time necessary for each contact is usu- 
ally from ten to fifteen or twenty minutes. These applications ought 
to be renewed once in four hours, when the symptoms are only severe, 
but when these are urgent, they should be made every two hours. 
We are in the habit of depending very much, also, on mustard foot- 
baths. When the oppression is severe, and especially when there is 
any coolness of the extremities, the use of a foot-bath simultaneously 
with the mustard poultice will often assist very much in relieving the 
breathing. 

In very young infants, antimony ought not to be emploj^ed, in my 
opinion, and in these, therefore, we need some other remed}^. In them 
ipecacuanha is much safer than antimony, audit is quite active enough. 
The best preparation is the syrup, of which from three to five drops 
may be given every two hours to infants six months old. In older 
children, also, in whom we have been obliged to suspend the antimony, 
and in those in whom its use has been contraindicated by delicacy of 
constitution or by feeble health, the ipecacuanha is preferable. The 
doses must vary with the age. At five years, about ten drops every 
two hours, in combination with the same quantity of spirit of nitrous 
ether, is a proper dose. When the child presents a pale surface and a 
languid expression, and particularly when the skin is very slightly 
warmer than usual, or coolish, the following prescription has proved a 
most useful one in our hands : 

R. 



Liq. Ammon. Acetat., 


. . . f^ss. 


Sj'rup. Ipecac, 


. . . m- 


Liq. ]\lorph. Sulphat., 


. gtt. xl 


Syr lip. Acacias, 


. . . f^j- 


Aquffi, 


• Jjjss.- 


Ft. mistura. 





The dose of this is a teaspoonful for a child two years old, to be re- 
peated every two hours. Should there be any nausea present, the 
syrup of ipecacuanha ought to be reduced to half the quantity; and if 
there be an}^ drowsiness, the morphia must be left out. 

In very severe cases of the disease, in which the dyspnoea is exces- 
sive, the pulse rapid and small, the skin cool and pale, the jactitation 
very great, and when there is present extensive mucous and subcrej^i- 
tant rale, the treatment generally recommended is the frequent employ- 
ment of emetics, and the French authors usually prefer tartar emetic. 
For our own part, we would not venture to administer, under such cir- 
cumstances, so powerful a remedy, and especially so potent a sedative, 
as antimony, one that we have so often known to cause alarming and 
dangerous prostration in children laboring under much slighter dis- 
orders than suffocative bronchitis. If any emetic be given, it ought to 
be one of milder action and less perturbing influence than tartar emetic, 
and we should choose, therefore, either ipecacuanha or alum. The 
plan of treatment we prefer, however, is to make assiduous use of 
counter-irritants, and to give internally the spirit of Mindererus and 



TREATMENT. 217 

a weak decoction of seneka; or we may combine with the decoction of 
seneka, in a suitable form, small doses of the muriate or carbonate of 
ammonia. Depletion is, in these cases, entirely contraindicated ; we 
may, however, with advantage apply a few small dry cups to the dor- 
sum of the chest in the interscapular space, or over the lower lobes of 
the lungs. 

In the bronchitis of children it often becomes proper and necessary 
to make use of stimulants. In the suffocative form, when the symp- 
toms assume the character described in the last paragraph, small doses 
of brandy or wine-whey may be administered alternately with the 
spirit of Mindererus, with great advantage. In milder cases, also, 
when a sudden increase of the dyspnoea occurs, especially in feeble and 
debilitated subjects, and when we may suppose, from the character of 
the rational and physical signs, that collapse of portions of the lung 
has taken place, it is best to abandon for the time all nauseating reme- 
dies, and to make use simply of brandy in doses of from five to twenty 
drops every half hour or hour, or of wine-whey in dessert or table- 
sj)Oonful doses, and of counter-irritants, with very light fluid nourish- 
ment. 

In cases where there is such marked debilit}^, tonics are very useful, 
and good results may be obtained from the administration of quinia, 
which was strongly recommended a few ^^ears ago, in the form of cap- 
illary bronchitis occurring in tropical climates, by Dr. Cameron (^London 
Lancet^ November 9th, 1861). 

In cases of this kind, we have used with great advantage of late 
years small doses of quinia, prepared as follows : 

R. — Quinise Sulphat., gr. vj. 

Acid. Sulph. Dil., gtt. xij. 

Syrup. Simp., f.l^s. 

Aquae, fjijss. — M. 

Give a teaspoonful every two hours, to children two or three years old. 

In older children the proportion of quinia to the dose ought to be 
doubled. If this should sicken, as it will sometimes do by the disgust 
its bitterness produces, and the consequent resistance to the doses, it 
is best to lay it aside after two or three trials, and to administer the 
quinia in the form of powder mixed with a little extract of liquorice 
and sugar, or to substitute the following: 

R.— Elix. Cinchon. Flav., f^ij. 

Curacoa, f^ij. 

Acid Sulph. Dil., '"iKxij. 

Aquse, fgijss.— M. 

Dose, a teaspoonful every two hours. 

The child ought to be laid on an inclined plane of pillows, and, with 
the exception of turning it gently towards one side or the other, from 
time to time, it should be kept perfectly quiet. These directions are 



218 BRONCHITIS. 

particularly important in very young children, as it is in them that 
debility and exhaustion of the muscular forces are apt to bring about 
the state of collapse just referred to. 

As an example of the kind of case in which stimulants are useful, 
and to show also the dangerous effects which antimony sometimes pro- 
duces, we will quote the following: A girl between seven and eight 
years old, was attacked while in good health with severe bronchitis. 
On the. second day, when we were called, she was very much oppressed, 
the skin was hot and dry, the pulse rapid, and the surface pale. We 
ordered a cupping to the amount of four ounces, with some dry cups 
besides, over the back, and two drops of antimonial wine with ten 
drops of sweet spirit of nitre to be given every two hours. On the 
third day a blister was applied over the sternum. On the fourth day 
we found the child in the afternoon very pale, dozing or tossing about 
on the bed, and sometimes rising up on her hands and knees with a 
bewildered look; she was inattentive, so that it was almost impossible 
to catch her e^^e; the eyes were sunken, and the countenance was dis- 
tressed and anxious; she moaned constantly and looked very ill; the 
skin was still hot; there was neither vomiting nor purging. The respi- 
ration was very much oppressed, and she coughed a good deal, though 
not so much as before. We suspended the antimony at once, and gave 
a teaspoonful of brandy in water, directing it to be repeated in three- 
quarters of an hour; after the second dose a teaspoonful was to be 
given in a wineglassful of milk and water every two hours through- 
out the night. On the following morning, the child looked better; she 
was less pale, and the eyes were not so excavated. The breathing was 
better. She was still very drowsy, but often waked partially with 
screaming and affright, and when awake took very little notice. The 
milk and brandy were continued every two hours. On the afternoon 
of this day, all the unpleasant symj^toms had disappeared; there 
remained only those indicative of a slight bronchitis, and she was soon 
quite well. ]S"ow it seems to us exceedingly clear that, had the anti- 
mony been continued in this case, on account of the hot, dry skin, 
oppressed breathing, frequent cough, and from the absence of vomiting 
or purging, the child would have died. 

The most important points in the treatment of chronic cases, are to 
insist upon a rigorous and persevering regulation of the hygienic con- 
ditions of the patient, and to make use of tonic, balsamic, and expec- 
torant remedies. The child should be carefully and warmly clothed, 
and. when at home, kept in dry, well-ventilated, and, if possible, airy 
rooms, at a uniform temperature. The living room of such a child 
ought to be heated in winter by a wood-stove, or open wood-fire, if that 
is sufficient to keep up a proper temperature. In our cold winters we 
have found no plan so good as a well-managed wood-stove. Coal fires 
cannot be lowered or extinguished at night, as they ought to be, and 
often keep up, through the day, too high a temperature. They are un- 
manageable. 

These, indeed, constitute the truly important part of the treatment, 



TREATMENT OF CHRONIC FORM. 219 

for without them, there is but little chance that drugs of any or of all 
kinds, diet, or any other measures, will be of any real service. The 
dress and temperature ought to be the first things attended to, and 
atter them, and as a secondary matter, certain medical substances will 
assist in removing the disease. The child ought to be taken as often 
as possible into the air in fine weather, and only in fine weather. The 
diet should be selected Avith a strict view to the improvement of the 
strength and vigor of the constitution; the food may consist, if the 
child be of proper age. of light meats, of j^otatoes and rice, as the only 
veojetables. and unless there is some eontraindicatins; circumstance, of 
a small quantity of wine with the midday meal. The best wine is port, 
of which one or two tablespoonfiils maybe given in a considerable quan- 
tity of water. 

Tonics must be administered throughout the course of the disease, or 
until the appetite and strength shall have improved to such an extent 
as to make them no longer necessary. The best are quinine, in the 
dose of a grain morning and evening, to be continued for several weeks; 
or, when the child is thin and anaemic, small doses of arsenic with iron, 
as recommended in the article on eczema, and cod-liver oil, in doses of 
half a teaspooufnl to a teaspoonful, three times a day after meals, either 
pure or in some carefully-made emulsion, wnll often greatly assist in 
curing these chronic forms of catarrh. 

In one case of chronic bronchitis, which came under our care, the 
patient recovered under careful regulation of the hygiene, and the use 
of a decoction of seneka, prepared by boiling a drachm, each, of seneka 
and liquorice roots, in a j)int of water, to half a pint. The decoction 
was strained, and a large teaspoonful given three times a day. The 
remedy was continued during a period of two months; under its use 
the child grew fat and strong, and recovered entirel}^ from the disease. 

Other remedies, proposed by different authors^ are the various 
resinous f)rep^i*ations, the balsams of tolu and copaiba, benzoin, and 
the sulphurous mineral waters. In cases of long-standing, where 
mucous lales persist throughout the lower part of the lungs, show- 
ing an abundant morbid secretion, tannic acid has been found, by 
several good authorities, of much service. While these means are 
employed, it is recommended, also, to make use of counter-irritants. 
If any are used, they ought to be such as will not produce too much 
inflammation of the skin; as, for instance, weak Burgundy pitch 
plasters, daily frictions with hartshorn and sweet oil, a simple diachy- 
lon plaster, or very mild pustulation with croton oil. 



220 EMPHYSEMA, 



AETICLE lY. 

EMPHYSEMA. 

Emphysema of the lungs is of quite frequent occurrence in children. 
It is much more general!}^ met with in an acute form, developed dur- 
ing the progress of some pulmonary disease, than in the chronic form 
which it so often assumes in the adult. It is probable, however, that in 
many cases of asthma in childhood, there is an emphysematous condi- 
tion of the lungs which has been gradually developed at an early pe- 
riod of infancy, in consequence of the respiratory embarrassment at- 
tending rachitic disease of the thorax. There is probably in such 
children a congenital delicac}' and weakness of the lung-tissue, and 
subsequently, if the constitution is re-established, and the deformity of 
the thorax removed, as it frequently will be, there ma}" be a restoration, 
to some extent, of the elasticity of the pulmonary tissue, with a corre- 
sponding decrease in the evidences of emphysema. It is also highly 
probable, judging from the frequency with which, in fatal cases of 
acute pulmonarj" disease in young children, more or less marked le- 
sions of emphysema of the lungs are found, that this condition is fre- 
quently developed to a certain degree in the course of such cases which 
recover, and that subsequentl}' the lung-tissue regains its normal state. 

Anatomical Appearances. — The term emphysema of the lungs, is 
usually employed to include two conditions essentially dissimilar, and 
to only one of which it is in reality applicable. One of these is vesicular 
emphysema, which is dependent on dilatation oV coalescence of the pul- 
monary air-cells, without any escape of air into the connective tissue of 
the lung, and which would, therefore, be more correctly called rarefac- 
tion of lung-tissue. The use of the term vesicular emphysema is, how- 
ever, so universal and long-established, that it does not seem desirable 
to discard it. The other variety is interlobular or true emphysema, in 
which the air escapes from some point into the connective tissue of the 
lung, and dissects its way between the lobules and under the pleura. 

In vesicular emphysema the portions of lung usually worst affected 
are the apex and the anterior border; it may, indeed, be limited to 
these parts, or may be present, in varying degrees of intensity, along 
the base and even over the entire surface of the organ. Usually it is 
present in both lungs simultaneously, though often much more highly 
developed on one side than the other. 

The dilatation of the vesicles causes marked enlargement of the part 
affected, and when both lungs are seriously involved, the}" project for- 
wards, occupying the mediastinal space, with their anterior borders 
closely approaching each other. The emphysematous portions do not 
collapse when the thorax is opened; they are pale, dry, and bloodless, 
and, when pressed with the finger, afford a soft, doughy feeling, with 
but an imperfect sense of crepitation. On examining the surface care- 
fully, the dilated vesicles are clearly visible, forming clear, usually 



ANATOMICAL APPEARANCES. 221 

round spaces as large as a pin's head or a millet-seed. The effect of 
this distension upon the surrounding viscera and upon the shape of the 
thorax are the same in kind, though not so great in degree, as are met 
with in the adult. The distended anterior portion of the left lung covers 
more of the heart than normal, and tends to depress this organ down- 
wards and to the right. In the same way when extensive emphysema 
of the right lung is present, the liver is usually depressed. If both lungs 
are affected with marked and diffuse emphysema, the thorax is consid- 
erably distended, the curve of the ribs is increased, while they are ele- 
vated so that their course becomes more horizontal, and the thorax 
becomes shorter, deeper in its antero-posterior diameter, and more 
rounded. 

The other variety of emphysema — really the only one which strictly 
merits the name in its usual intention — is the interlobular. Here the 
air makes its escape from a rupture of some air-vesicle or minute bron- 
chiole into the connective tissue of the lung, and then readily makes its 
way along the bronchial tubes between the lobules so as to reach the sur- 
face of the lung. Here it presents itself in the form of minute bubbles 
of air, of rounded or elongated form, easily recognized by their paleness 
and transparency, usually arranged in irregular, curving and branch- 
ing lines, and which can be proved to be in the interstices of the lobules 
by the fact that they can readily be pressed by the finger from one 
place to another, or forced to coalesce. When these little bubbles are 
xhiekly crowded together they produce an appearance well compared 
by Rokitansky to froth. Associated with them are often found larger 
bullae, where the air has separated the pleura from the surface of the 
lung; these form flattish, convex prominences above the surrounding 
surface, and are freely movable. It will be understood that in inter- 
lobular emphysema of the lungS;,the size of the organ is comparatively 
little affected, and consequently that little or no influence is exerted by 
it upon adjacent viscera or upon the shape of the thorax. This condi- 
tion is comparatively rare, and is not usually associated with marked 
vesicular emphysema; indeed, the anatomical relations of the two forms 
are not clearly understood. In cases where the pleura is stripped off 
from the lung over a considerable space, the membrane may be rup- 
tured and air escape into the pleural cavity, constituting pneumotho- 
rax, examples of which accident will be found in our article on this 
latter affection. In other cases, the air makes its way along beneath 
the pleura to the- root of the lung, or by penetrating into the sub- 
stance of the organ, and following up the divisions of the bronchi, it 
reaches the same point. It may then pass into the mediastinal spaces, 
where the loose connective tissue becomes highly emphysematous, so 
as to present numerous large vesicles with delicate walls, altogether 
resembling the appearances seen in animals in the slaughter-house. 
From the mediastinum the air readily passes upwards into the con- 
nective tissue of the neck, where it may first produce a crepitant swelh 
ing in the suprasternal, supraclavicular, or inframaxillary regions; and 
may even extend thence over the surface of the trunk and extremities 
so as to produce general emphysema. 



222 EMPHYSEMA. 

In the following interesting case, which has already appeared in 
j)rint,^ the subcutaneous emphysema did not extend below the clavicle. 
The minute perforation on the anterior surface of the upper lobe was 
j)erhaps due to the inflation of the lungs at the time of the examination, 
or may have occurred just before death. It would certainly have led 
to pneumothorax, had it been earlier present : 

Case. — Acute Miliary Tuberculosis: Cough and Dyspnoea : Cervical Emphysevia — 
Interlobular Emphysema — Interlobular Emphysema with Perforation of the Pleura : 
Emphysema of Mediastinum and Neck. — John T. was born of a stout, hearty young 
woman, 17 years of age, who nursed him; and he seemed to thrive until eight days 
before his death, which took place January 24, 1868, at the age of four months. The 
symptoms during his sickness were dyspnoea, occasional dry, hacking cough, and 
anorexia. A few days before his death subcutaneous emphysema made its appear- 
ance over the lower part of the neck in front, spreading over both sides, and alter- 
ing the entire contour of the neck, but not descending below the clavicles. The 
post-mortem examination was made fifteen hours after death. 

The head was not examined. The subcutaneous emphysema persisted as above de- 
scribed. 

On removing the sternum, the mediastinal spaces were found much distended with 
air, the meshes of the connective tissue in some spots forming vesicles more than one 
inch in diameter, and suggesting forcibly the appearances often seen in animals in 
the slaughter-house. The emphysema extended up along the trachea and larynx, 
and to a considerable distance on either side of the neck. There was not a trace of 
decomposition of the tissues. The lungs collapsed but slightly"; the posterior por- 
tions w^ere deeply congested, purplish, and almost non-crepitant, but expanded 
almost fully on inflation. There was neither pneumothorax nor pleuritic effusion or 
adhesions. The larynx, trachea, and lungs were removed, and inflated under water, 
when air was found to escape from the right lung in two places — on the anterior 
face of the upper lobe, and on the inner surface of the apex. On examining the rup- 
ture of the anterior surface of the upper lobe, the opening was found to be very small, 
and to be seated in the midst of a spot where the pleura was separated from the 
lung so as to form a large vesicle. There were other smaller pearl-like vesicles stud- 
ding the surface of the lung. The apex was the seat of numerous miliar}'^ tubercles, 
both in the substance of the lung and immediately beneath the pleura. At one point 
on its inner aspect there was such a subpleural deposit, half an inch in diameter, 
which had undergone cheesy change, and in the centre of which there was an ulcer- 
ated opening in the pleura. The escape of air through this perforation was prevented 
by the close apposition of a tuberculous bronchial gland, about half an inch in diam- 
eter, which lay immediately on the right bronchus. The other bronchial glands, 
especially on the right side, were also tuberculous. The left lung presented no per- 
foration of the pleura. At several points, especially along the anterior edge of the 
lung, there were large emphysematous bullse, one inch long by half an inch wide, 
and in the neighborhood were numerous smaller vesicles of the same nature. On 
incising the lung near these, small clusters of gray miliary t'ubercles were found. 
Miliary tubercles were also found on the peritoneal investment of the liver and 
spleen, and in the substance of these organs and of the mesenteric glands. There 
were tmall irregular ulcers in the lower part of the ileum, and numerous small yel- 
lowish submucous deposits in the csecum. 

Causes. — Although the vesicular and interlobular forms of emphy- 
sema are anatomically quite distinct, they may advantageously be con- 

^ W. Pepper, On some Cases of Emphysema of the Neck. Philada. Med. Times, 
August 1, 1872. 



MECHANISM OR MODE OF PRODUCTION. 223 

sidered in connection with each other as regards the mode of their de- 
velopment. 

Age. — Yesicuhir emphysema, though a frequent sequel of acute tho- 
racic diseases in children, cannot be regarded as a disease of childhood 
in the same sense as the interlobular form. It is true that the delicacy 
of the Avails of the air-vesicles during early life would seem to favor the 
occurrence of dilatation, but experience shows that it does not favor 
the development of emphysema nearly so strongly as does the gradual 
degeneration and weakening of the walls of the air-vesicles which 
comes on in advanced years. 

Interlobular emphysema, on the other hand, is much more frequent 
in children, and reaches degrees of severity which are scarcely found 
in later life. So, too, the occurrence of subcutaneous emphysema, in 
consequence of the rupture of some minute bronchiole or air-vesicle, 
with the production of subpleural and then mediastinal emphysema, is 
an accident almost limited to early childhood, since of the recorded 
cases (about 25) in which it has occurred, four-fifths (20) have been ob- 
served in young children. Of these 20 cases of "general emphysema 
in children," to employ Roger's term^ (of which 19 were collected by 
him, and 1 subsequently published by one of ourselves),^ 6 occurred 
under the age of 2 years, 10 between 2 and 4, and only 4 between 10 
and 15 years of age. 

Previous Diseases. — In children, emphys(^ma occurs as a sequel to 
some other disease, pulmonary or laryngeal. The affections which 
most strongly predispose to it are hooping-cough, the bronchitis of 
measles, simple bronchitis, pneumonia, and pseudo-membranous croup. 
Of all these, hooping-cough is by far the most fruitful cause. It will 
be observed that the diseases named present the common symptom of 
severe cough, often attended with impediment to the escape of air, either 
from spasm of the air-passages, or accumulation of secretion in the 
bronchi, or mechanical obstruction of the larynx by false membrane. 

Mechanism or Mode of Production. — The way in which pulmonary em- 
physema is developed has been made the subject of frequent and con- 
flicting speculation. Of the two chief theories which have been ad- 
vanced in explanation, one (the inspiratory) regards the overdistension 
of the vesicles as the result of the excessive operation of the forces con- 
cerned in inspiration; the other (the expiratory) explains it as caused 
by violent but impeded expiratory efforts. The inspiratory theory is 
still upheld by some eminent writers, but clinical observation is leading 
to its abandonment. In its original form as advanced by Laennec, it 
was based upon the erroneous notion that the forces of inspiration 
are greater than those of expiration, and that consequently emphy- 
sema might result from mere excessive inflation of the lungs. This 
has, however, been universally abandoned as of general application, 
since the discovery of the important fact that in forcible breathing the 
power of expiration is considerably (at least one-third) greater than 

1 Henri Koger, Archives de Medecine, 5eme ed., tome xx, pp. 129, 288, 403. 

2 W. Pepper {loc. ante cit). 



224 EMPHYSEMA. 

that of inspiration; though it is probable that in some morbid condi- 
tions of the pulmonary tissues, violent inspiration may of itself be capa- 
ble of producing emphysematous distension of the air-vesicles. 

The form of the inspiratory theory, which is still retained by some 
authorities, is based upon modifications introduced by Dr. William 
Gairdner, and is an expansion of the idea that if certain portions of 
the lungs are, from collapse or other cause, incapable of expansion, the 
atmospheric pressure will determine excessive dilatation of the re- 
maining portions, in order to prevent the occurrence of a vacuum as 
the thoracic walls expand. There are, however, such grave objections 
to this theory, which, it will be observed, rests upon the supposition 
that the expansion of the thorax and the amount of air inspired remain 
at the normal point, although portions of the lungs are collapsed or 
otherwise rendered unable to expand, that we are strongly inclined to 
regard the expirator}^ theory as the only one capable of general clin- 
ical application. We owe to Sir William Jenner chiefly the satisfactory 
refutation of the principal argument which was formerly brought 
against this latter theory, that " the expiratory act is mechanically 
incapable of producing distension of the lung, or of any part of it. 
The act of expiration tends entirely towards emptying the air-vesicles 
by the uniform pressure of the external parietes of the thorax upon 
the whole pulmonary surface; and even when the air-vesicles are main- 
tained at their maximum o^ normal state of fulness by a closed glottis, 
any further distension of them is as much out of the question as would 
be the further distension of a bladder, blown up and tied at its neck, 
by h3xlrostatic or equalized pressure applied to its entire external sur- 
face " (Gairdner). A little consideration of the anato.mical relations 
of the lungs to the thorax shows the falsity of this argument. The 
different portions of the lungs are in contact with surfaces and tissues 
of very different degrees of resisting power, and while the entire pos- 
tero-lateral portions are supported by the unyielding ribs, the apices 
are covered only by soft tissues, and the anterior borders of the lungs 
are supported externallj^ by the comparatively yielding costal carti- 
lages, while centrally they are able to encroach considerably upon the 
tissues of the mediastinal spaces. In ordinary free expiration the air 
is forced out of the lungs by a pressure so moderate and gradual that 
even the weakest parts of the thoracic walls are suificiently firm to 
maintain it. But when the expiratory efforts become more violent, 
the air is pressed with great force from the central, basic, and lateral 
portions by the ascent of the diaphragm and the compression of the 
thorax, while the outward current from the apices and anterior mar- 
gins is comparatively feeble. If, therefore, from any cause the normal 
relation between the volume of the expiratory current of air and the 
calibre of the large bronchi be disturbed, the portion of air which can- 
not escape will be driven violently into the apices and anterior mar- 
gins, not only overcoming the outward current of air proceeding from 
those portions of the lungs, but producing an excessive degree of dis- 
tension of their air-cells. The strongest possible confirmation of the 



SYMPTOMS. • 225 

truth of this view is to be found in the fact that emphysema, both of 
the vesicular and interlobular form, is found to be developed in the 
various parts of the lungs in precise correspondence with the degree in 
which they lack firm external support. 

There are two ways in which a disturbance of the above relations 
maybe effected: either by an obstruction in the air-passages, w^hich 
prevents the free escape of the air, or by the expiratory act being so 
sudden and violent that the volume of air hurriedly forced from the 
air-vesicles is too great to pass freely through the primary bronchi. 
Instances of this latter condition are familiar to all in violent fits of 
coughing, during which, even when there is no obstruction in the air- 
passages, the degree of distension of the apices may be appreciated by 
the bulging of the supraclavicular tissues. The full pulmonary reso- 
nance, which is elicited by percussion of this bulging, proves conclu- 
sively that it is due to distension of the apex; and it is therefore easil}^ 
understood how the repeated operation of such a cause may gradually 
lead to the development of vesicular emphj'sema, or how in an abrupt, 
violent, and prolonged expiratory effort, attending a fit of coughing, 
there may be a rupture of some minute bronchiole or air-vesicle, fol- 
lowed by interlobular emphysema. Undoubtedly, also, the mechanical 
effects of such overdistension will be greatly enhanced by morbid condi- 
tions of the lung-tissue which weaken its elasticity, such as are present 
in severe bronchitis, especially when associated with constitutional dis- 
eases. Far more frequently, too, there is associated some cause of par- 
tial obstruction to the escape of air, such as the spasmodic contraction 
of the air-passages in hooping-cough, the presence of layers of false 
membrane in the larynx or trachea, or thickening of the bronchial 
mucous membrane with plugs of viscid tenacious mucus in the tubes. 

It is very possible, also, that in some cases interlobular emphysema 
may be caused by the implication of a minute bronchiole in the prog- 
ress of the softening of some spot of diseased tissue, so that the air 
might find entrance to the' interstitial connective tissue without any 
mechanical cause of overdistension and rupture of air-vesicles. Thus in 
the case reported above (p. 222) there was certainly a very close con- 
nection between the position of the patches of tuberculous deposit and 
the bullae of subpleural emphysema, so much so that we cannot doubt 
that the escape of air was in some way favored by their presence. In 
another case also, where interlobular and subpleural emphysema, fol- 
lowed by pneumothorax, occurred, and which is reported at length in 
our article on this latter affection (p. 255), it seemed to us that proba- 
bly the softening of superficial circumscribed patches of pneumonia had 
opened into minute bronchioles, and thus allowed the escape of air. 

Symptoms. — We have already seen that in young children emphy- 
sema occurs usually in an acute form in connection with some acute 
disease of the lungs. Although, therefore, its presence may be sus- 
pected in such cases where violent paroxysms of cough have occurred, 
associated with prolonged, severe dyspnoea, there are scarcely any phys- 
ical signs by which its existence can be determined. The percussion- 

15 



226 EMPHYSEMA. 

resonance will continue clear, or even become somewhat exaggerated, 
and this fact of the absence of anydulness (due to pneumonia, collapse, 
or pleural effusion), in a case of hooping-cough or bronchitis, when severe 
cough has occurred with unusually extreme dyspnoea, is of diagnostic 
value. The respiratory murmur undergoes no immediate change in its 
character, and it is not possible, owing to the violent and rapid respi- 
ratory efforts of the child, to detect any diminution in the force of the 
murmur. Expiration in such cases is, however, often already pro- 
longed and laborious. 

The development of acute vesicular or interlobular emphysema, then, 
is suspected rather on account of the character of the disease from 
which the child is suffering than from any distinct substantive symp- 
toms of these conditions. Exception is to be made, however, of the rare 
cases, in which suddenly, in the course of an acute pulmonary disease, 
a swelling is noticed at some part of the neck, or in the subclavicular 
space, which on palpation is found to crepitate. This may be regarded 
as, in all probability, connected with extensive interlobular emphj^sema. 
The other chief cause of such subcutaneous emphysema is perforation 
of the larynx or trachea, and the previous symptoms will enable us to 
exclude this rare condition w^ithout difficulty. 

In other cases, however, vesicular emphysema in children assumes 
the chronic form, more usually found in adults, and will then be attended 
with the well-known sjnnptoms of this affection. At times, it occurs 
evidently as a sequel to some acute pulmonary disease, in the course of 
which it has been developed in the manner above described, and after 
the original disease has passed away, it persists, either owing to original 
w^eakness of the lung-tissue, or to the extreme degree of the dilatation 
of the air-vesicles. At other times, it is met with as a purely chronic 
affection, which may begin in early childhood, and gradually increase 
until the disease is fully developed. In such patients there is probably 
some congenital weakness and tendency to degeneration of the pulmon- 
ary tissues. It is not unfrequently found th'at there are also evidences 
of rachitic disease of the ribs in such cases. 

Children with chronic emphysema present various degrees of habitual 
dyspnoea, which is always readily increased by exertion. They are 
very subject to attacks of bronchitis, during which the breathing is 
much embarrassed and wheezing, the chest is fall of sonorous and sibil- 
ant rales, and the cough occurs in severe paroxysms without much ex- 
pectoration. During these attacks, not unfrequently the child suffers 
at night from violent paroxysms of spasmodic asthma. Indeed, it may 
happen that attacks of asthma will be induced in em^Dhysematous chil- 
dren by the most trifling causes, such as changes of weather, indiges- 
tion, and the like. The attacks of bronchitis vary greatly in different 
cases in their relation to season and temperature ; in some they occur 
almost exclusively during the damp, cold weather of fall and winter, 
w^iile in others they are most frequent and severe during summer and 
spring, and the child finds more relief during cold weather. 

The cough varies much in its intensity and character. During the 



SYMPTOMS. 227 

attacks of bronchitis it is usually very severe, occurring in long spells, 
at lirst with a little mucous expectoration, and later, as the attack passes 
over, with more abundant muco-purulent sputa. In the intervals of the 
attacks it may continue as an occasional dry and rather wheezing cough, 
or it may be more troublesome on account of a certain degree of chronic 
bronchitis being always present, or finally it may altogether subside. 
After the disease has lasted a considerable time, however, cough may 
become persistent, occurring most severel}^ at certain periods of the day, 
and attended with a considerable quantity of muco-purulent expectora- 
tion. In such cases, when emphysema is conjoined with chronic bron- 
chitis, the suspicion is apt to arise that the child is suffering from 
phthisis, and the positive determination of the diagnosis may indeed 
be attended with some difiSculty. The reader is also referred to the 
remarks made in this connection on the subject of chronic bronchitis 
(see p. 211). 

In young children under the age of 5 or 6 years, emphysema rarely 
reaches so great a degree, or persists for so long a time as to induce 
marked changes in the shape of the thorax, or to seriousl}^ affect their 
nutrition. In children somewhat older, however, when the disease is 
more severe and chronic, it may be attended with most of the s^'mp- 
toms familiar in the adult. The appearance of such children is apt to 
be frail and delicate, their muscular system develops slowly, and they 
become so readily fatigued and out of breath that they avoid play or 
much exercise. The shape of the thorax becomes gradually altered ; the 
shoulders grow high and rounded, and the chest is prominent and dis- 
tended in its upper part, ^vhile owing to imperfect expansion of the 
lower lobes, there may be perceptible retraction of the base of the 
thorax in front, or even a marked depression around the entire base of 
the chest. Of course, this is likely to occur to a more marked degree 
if the emphj'sema is associated with rickets. 

The physical signs vary greatly with the extent and degree of the 
emphysema. In cases where it is limited to small areas of the lungs, 
scarcely any physical sign can be detected; but in partial and more 
severe forms, the following phenomena can be observed : The respira- 
tory movements are restricted especially in the way of expansion; and 
during inspiration the movement is chiefly one of elevation effected by 
overaction of the upper respiratory muscles, and attended with an 
evident deepening of the depression around the base of the chest. The 
percussion-resonance is very full and clear, or even tympanitic, though 
owing to the marked resonance normal in children, it is difficult to de- 
termine the degree of its exaggeration. There may be associated some 
impairment of resonance over the retracted base of the thorax, and 
especially posteriorly, where there may be congestion of the lung with 
accumulation of secretion in the air-passages, due to the coexisting 
bronchitis. The respiratory murmur is weakened, though rarely to the 
degree noticed in adults; the expiratory murmur is decidedly prolonged 
and frequently wheezing. Both inspiration and expiration are apt to 
be accompanied w^ith sonorous and sibilant rales. These, and especially 



228 EMPHYSEMA. 

the sonorous rales, are most markedly developed over the posterior parts 
of the lungs, near the larger bronchi. In some cases, moist rales may also 
be heard over the postero-inferior parts of both lungs, owing to the pres- 
ence of an unusually large quantity of secretion in the smaller bronchial 
tubes. During one of the acute aggravations of the bronchitis, attended 
with nervous asthma, to which we have above alluded as being so fre- 
quent in such patients^ a dry sibilant rale, distributed over the entire 
thorax, is often the only sound heard accompanying the labored respi- 
ration. 

In marked cases, there will also be impairment of the resonance and 
fremitus of the voice, cough or cry. The apex-beat of the heart may 
be concealed by the distended lung, and the area of cardiac dulness 
is diminished. As before said, the alterations of the shape of the thorax 
and the marked physical signs now described are very rarely observed 
in children under the age of 5 or 6 years, and become more constant 
and more marked at later periods of childhood. 

Case. — A., set. 8 years, came under observation in the fall of 1873. The daughter of 
healthy parents, she was nursed until the age of 2 years. She suffered much from oc- 
casional diarrhoea for the first three years of life, but then improved in this respect. 
She cut her teeth without difficult}'', and as rapidly as usual ; began to walk at usual 
age. Has always perspired profusely at night, especially about neck and head, and 
when an infant was very troublesome from constantly kicking off the bedclothes at 
night. There was no muscular soreness. 

At the age of 4 years she had a severe attack of spasmodic croup, and since then 
has been subject to frequent attacks of bronchitis, often associated with asthma. At 
first, there were onl}^ a few attacks each year, but for the past year the}^ have followed 
each other with scarcely any intermission. She always suffers more during summer 
than in winter, and has found relief on several occasions by spending a few weeks 
during the summer at the seashore. The attacks usually begin as a simple catarrh, with 
sneezing for a couple of days, followed then by wheezing cough, shortness of breath, 
and nocturnal attacks of asthma. There is habitually dyspnoea on exertion, and the 
child has grown to care little for play, and to prefer staying quietly indoors. Lately 
there has been persistent and severe cough, with muco-purulent expectoration, fever- 
ishness, loss of appetite and strength. One year ago alteration in the shape of the 
chest was noticed. She was very much benefited last fall (when she was seen once 
by us) by the use of muriate of ammonia in full doses, with a mixture of quinia and 
arsenic ; but after its cessation she has had a return of her troublesome symptoms. At 
present she is a rather tall and delicate-looking child, with high rounded shoulders. 
The upper part of the thorax, from above the clavicle down to the fourth rib, is dis- 
tended. Below that level there is retraction of the anterior chest- walls, and on passing 
the finger parallel to the sternum there is a quite marked groove about one inch from 
each side of that bone, caused by incurvation of the ribs along that line. The expan- 
sion of the chest is limited. The apex-beat of the heart is at the sixth rib nearly 2^^ 
below line of nipple, being apparently somewhat depressed. Percussion-resonance is 
exaggerated and almost tympanitic over supra- and infra-clavicular spaces, while over 
the retracted portions of the chest it is slightly impaired. The vesicular murmur is 
impaired, and over the superior part of the chest expiration is evidently prolonged. 
No rales are heard anteriorly, but posteriorly, at the base, and especiall}^ about the 
roots of the lungs, snoring rales are heard. 

The case appears to be one of emphysema of the upper parts of the lungs, associated 
with deformity of the chest, partly due to rickets, partly to the emphysematous dis- 
tension of the lungs, and attended with a varying degree of chronic bronchitis, with 
,a tendency to spasmodic asthma. 



I 



DIAGNOSIS — PROGNOSIS. 229 

She was ordered careful diet and clothing ; salt baths daily ; regulated gymnastic 
exercises with her arms ; and the following medicines : 

R. Potass. lodid., g^- ij. 

Potass. Bromidi, gr- v. 

Syr. Ferri lodidi, gtt. v. 

Syr. Tolutani, . gtt. xxv. 

Aqufe, ........... f^ss. 

Ft. sol. S. t. d. 

The use of this was followed by improvement in appetite and strength, and by a 
marked diminution in the frequency and severity of the asthmathic attacks. As, 
however, the cough continued quite severe, with abundant loose mucous rales through- 
out the chest, the treatment was changed to the following: 



aafgj.-M. 



R. Syr. Phosphat. Comp., f^ij 

Elix. Calisavffi, ........ 

Aqufe, .......... 

Dose. 2 teaspoonfuls in water before meals. 
And to relieve the cough : 

R. Ammonite Muriatis, ....... grs. Ixxij. 

Syr. Senegre, . . . . . . . . f^ss. 

Tr. Hyoscyami, ........ f'^iss. 

Ext. Pruni Yirg. Fluid., f3ss. 

Syr. Zingiberis, q. s. ad f^iij. — M. 

Dose. A teaspoonful in water three or four times in twenty-four hours, according 
to the severity of the cough. 

Under the use of these remedies, her improvement has been rapid and continuous. 

Diagnosis. — In regard to the detection of the acute form of emphy- 
sema at the time of its occurrence, we have already shown that there 
are no signs sufficiently distinctive, and that if any unusual severity or 
persistency of dyspnoea rouses the suspicion, we may only assume its 
presence in consequence of the great frequency with which it is devel- 
oped in certain diseases. 

This is even more true with regard to the interlobular than the 
vesicular form, except when the sudden appearance of subcutaneous 
emphj'sema proves its existence. 

If, however, emphysema becomes firmly established, and persists, it 
becomes attended with the well-marked symptoms already described, 
and there are then scarcely any conditions with which it can be con- 
founded. In almost all cases, there is associated bronchitis, either in 
the form of repeated acute attacks, or, more frequently, of a chronic 
form of varying degrees of intensity. It is therefore necessary to 
guard against overlooking the evidences of emphysema, and consider- 
ing such cases as simple forms of bronchitis. In cases where emphy- 
sema of long standing is accompanied by severe and chronic bronchitis, it 
maybe confounded with phthisis. Apart, however, from the fact that 
chronic phthisis is rare in childhood, a careful study of the history of 
the case, and of the physical signs, will enable us to avoid this error. 

Prognosis. — Only in extreme cases of emphysema in children is the 
prognosis so unfavorable as in this condition in adults. In many cases 
where there can be no reasonable doubt that it exists to a consider- 



230 EMPHYSEMA. 

able extent, the lung-tissue regains its contractility soon after the 
exciting cause of the emphysema has been removed, and all evidences of 
its existence gradually disappear. Even in more protracted cases, 
when the disease persists for some years, and leads to deformity of the 
thorax, there is ground for hope that, under the influence of the de- 
veloping constitution and frame, and sustained judicious treatment, 
considerable relief will be obtained. This is equally true in regard to 
the tendency to attacks of nervous asthma, which is so frequently asso- 
ciated with emphysema, as it is true of its other symptoms. Children, 
who, at an early age, suffer severely with such attacks even from the 
slightest causes, are frequently seen to entirely outgrow the distress- 
ing tendency, and to bear any change of climate or vicissitude of weather 
without inconvenience. 

The prognosis of mediastinal and subcutaneous emphysema depen- 
dent upon the interlobular form, is of course controlled entirely by the 
nature of the primary disease. It undoubtedly of itself aggravates the 
dj^spnoBa caused by the original pulmonary disease, but still very rarely 
reaches so extreme a degree as to endanger life. It must be borne in 
mind, however, that it is very frequently associated with pre-existing 
lesions of the lungs, which, either from their character or their extent, 
are almost necessarily fatal. Thus, of the 20 cases before referred to 
as on record, in only 4 has this accident been followed by recovery. It 
must, therefore, be regarded merely as a serious complication, but one 
which would not justify an altogether unfavorable prognosis in an 
otherwise curable condition. 

Treatment. — The treatment of cases of acute pulmonary disease, in 
the course of which it is suspected that emphysema has occurred, cannot 
be much modified on account of this complication. As it is, however, 
closely dependent, in such cases, upon the frequent and violent cough, 
the most important indication is to allay this by suitable antispasmodics 
and sedatives. At the same time, as the increased dyspnoea which is 
caused by the development of the emphysema must seriously add to the 
exhaustion of the patient, the utmost care must be exerted to sustain 
the vital powers, and to discard every depressing element from the treat- 
ment. 

The same remarks, which are used above with special reference to 
vesicular emphysema, apply with equal force to the interlobular form 
when it becomes complicated with mediastinal and subcutaneous em- 
physema. The onl}^ chance of recovery in such cases, is to be found in 
sedulously supporting the system until the primary disease (if of a 
curable nature) has passed away, and the effused air has been gradu- 
ally absorbed. This absorption may be, to some extent, hastened by 
gentle frictions on the emphysematous parts with the hand. In cases 
where the extent of the external emphysema is such as to threaten 
life, minute punctures may be made in the distended skin, and the 
escape of the air favored by gentle pressure with the hands towards the 
point of puncture. 

The most important field for medical treatment is, however, to be 






TREATMENT. 231 

found in those cases where emphysema, whether acute or not in its incip- 
iencj. has passed into a chronic or persistent form. The indications for 
treatment which here present themselves, are mainly to relieve the 
chronic bronchitis, which is almost invariably associated with emphy- 
sema, if it has not been its chief cause; to eradicate any rachitic ten- 
dency which often coexists, and, so far as possible, to counteract its re- 
sults; to guard against and relieve the acute attacks of bronchitis often 
accompanied with nervous asthma, from which such children suffer; 
and finally to favor, so far as lies in our power, the restoration of the 
dilated lung-tissue to its normal condition. 

There are several consideration^ of a general character, which will 
be found to have an important bearing upon these requirements. 

Change of climate, when it can be judiciously made, is often attended 
with excellent results, particularly as regards the bronchi tic irritation 
and the attacks of asthma. We have known children who suffered most 
severely from these conditions, which were aggravated by any trivial 
causes so long as they remained in their native place, but who on re- 
moval to other climates, received marked relief and gradually outgrew 
the disease. It is not at all necessarj^ that this change should be to a 
distant spot; often the most convenient, dry, elevated inland locality 
will answer excellentl3\ 

The clothing of such children should be carefully studied and regu- 
lated. "Without being so heavy as to oppress, it must be at all times 
warm enough to thoroughly protect; and at the same time there should 
be a suit of flannel or silk (consisting of an undershirt with long sleeves, 
and long drawers coming down to the ankles), of varying thickness to 
suit the season, worn throughout the year, to protect the surface of 
the body from the chilling effects of sudden vicissitudes of temperature. 

As further means to secure activity of the circulation and function 
of the skin, the use of salt-baths (of a temperature to suit the season), 
and followed by brisk rubbing with a coarse towel, are to be recom- 
mended. 

In no condition of the system is the use of gymnastic exercise more 
to be insisted upon. We should select those exercises with light dumb- 
bells or Indian clubs, which will tend to strengthen the muscles of res- 
piration, expand the lower portions of the chest, which, as we have 
already pointed out, are apt to be retracted, with some incurvation of 
the ribs, from the coexistence of rickets at an earlier age. As children, 
in whom emphysema assumes the chronic form, are usually over the 
age of 6 or 7 years, such exercises can be readily carried out. 

The selection of the diet should be made with care. It will often be 
found that all the symptoms are aggravated by any digestive disturb- 
ance, and we have seen, as is indeed frequently the case in emphysema 
of adults, violent paroxysms of nervous asthma induced by indigestion. 
As the digestion in such children is apt to be weak, this point requires 
the greater care. 

As regards medication, the most important remedies are such as will 
affect the constitution favorably. 



232 



EMPHYSEMA. 



We should recommend the use of cod-liver oil in properly graduated 
doses, and, especially where there are evidences of rachitic disease, 
the compound syrup of the phosphates or the lacto-phosphate of lime 
may be advantageously associated in the form of emulsion. If iron is 
not thus administered in the form of the phosphate, the oil may be 
given alone, and iron should be taken separately in some other combi- 
nation, as in the following : 



R. — Potassii Bromidi 
Potassii lodidi, 
Syr. Ferri lodidi, . 
Syr. Tolutani, 
Aquse, 

Ft. sol. S. — A teaspoonful th 




ice daily in a little water. 



The dose here directed is for a child of about 8 years of age. 

We have also found the prolonged use of arsenic for its constitutional 
effects of much value in some cases. 

Cough should be relieved, so far as possible, without the use of opi- 
ates and nauseating expectorants. Among the drugs which we have 
found most useful in controlling it, as well as in relieving the chronic 
bronchitis upon which it usually depends, are the iodide of potassium, 
which may be advantageous!}' combined with the potassium bromide, 
as in the above prescription, the bromide of ammonium, and the muri- 
ate of ammonia. If the cough be very troublesome, especially at night, 
tincture of hyoscyamus and minute doses of morphia maybe occasion- 
ally associated. It may, however, become necessary to substitute for 
these, or to combine with them, other alterative and stimulant expec- 
torants, such as seneka or copaiba. 

The use of quinia, and, at times, of strychnia with it, is indicated 
throughout a large part of the treatment for the useful influence of 
these drugs upon the digestion and general nutrition, and especially 
upon the tonicity of the muscular system. 

The acute attacks of nervous asthma which are apt to occur from 
time to time must be relieved at the moment by the prompt use of re- 
laxing emetics, hot mustard-water foot-baths, the inhalation of ether or 
of the smoke of stramonium cigarettes. The frequency of these distress- 
ing attacks will, however, be greatly influenced by the persistent em- 
ployment of the general treatment above sketched. 

Finally, it must not be forgotten that despite the obstinacy and se- 
verity of the symptoms of emphysema in some cases, and the positive 
alterations of the shape of the thorax, there is always reason to hope 
that, if w^e can succeed in removing the element of chronic bronchitis, 
and in favoring the expansion of the lower lobes of the lungs, so as in 
these ways to relieve the strain upon the upper portions of the organs, 
the distended vesicles will gradually regain their elasticitj'^ and as the 
thorax enlarges with advancing years, all symptoms of the disease will 
pass away. 



PLEURISY. 233 

AETICLE Y. 

PLEURISY. 

Definition; Frequency; Forms. — Pleurisy consists in inflammation 
of the pleural serous membrane. 

Idiopathic pleurisy is a rare disease under five years of age, and 
especially in the first and second years of life. After the age of five 
years it becomes more frequent. We have met with 28 cases of pleu- 
risy, of which we have kept notes. Of the 28, 26 were idiopathic, and 
2 secondary; one of the latter occurring during hooping-cough, and the 
other being accompanied by pneumonia, though the pleurisy was the 
predominant disease. Secondary pleurisy, on the contrary, or that 
which occurs in the course of other diseases, is common at all ages. 
31. Bouchut met with it in 23 out of 68 autopsies of new-born and 
suckling children. Of the 23, 9 accompanied acute pneumonia, 6 tuber- 
cular pneumonia, 5 entero-colitis, and 3 different other diseases. This 
form of the affection is rarely detected during life, being masked by the 
concomitant malady. 

We shall describe two forms of the disease, the acute and chronic. 

Predisposing Causes. — As to the influence of age, it has already 
been stated that idiopathic pleurisy is rare between birth and five 
years of age. It is certainly rare, during those years, in comparison 
with pneumonia, and especially with bronchitis, for we find that while 
we have met with but 15 cases of pleurisy of all kinds under five years 
of age, we have seen 28 of pneumonia under that age, and 105 of 
bronchitis under six years of age. Of 28 cases of pleurisy that we 
have seen, 26 were idiopathic, and of these one occurred at the age of 
three months; three between 1 and 2 years of age; one between 2 and 
3; four between 3 and 4; eight between 4 and 5; three between 5 and 
6; two between 6 and 7; three between 7 and 8; and one between 13 
and 14. Of the two secondary cases, one occurred at six weeks of age, 
and one between 4 and 5 years. Secondary pleurisy is said, by the best 
authorities, to be most frequent between one and five years of age, being, 
in this respect, just the contrary of the idiopathic form of the disease. 

Pleurisy is said to occur more frequently in boj-s than girls. Of 26 
cases, in which we noted the sex, 19 occurred in boys and 7 in girls. 
The idiopathic form is most apt to occur in vigorous and hearty sub- 
jects, while the chronic and cachectic forms attack those who are feeble 
and delicate. It is often, as already stated, a secondary affection, occur- 
ring particularly during pneumonia, and, after that disease, during 
rheumatism, scarlet fever, and Bright's disease. Season is another pre- 
disposing cause. It is most common during winter and spring, esj^eci- 
ally the latter. 

The exciting causes are very obscure in most cases. The only ones 
which seem to have been ascertained with any certainty, are exposure 
to cold and sudden changes of weather. It has been said to follow ex- 
ternal violence. In one of the cases that came under our own observa- 



234 PLEURISY. 

tion, the child had struck the affected side severely against a pointed 
stick on the day of the attack. 

Anatomical Lesions. — The serous membrane may retain its natural 
characters, which happens in the majority of cases, or it may present 
the different appearances indicative of inflammation. These are more 
or less minute and abundant injection and punctuation, and spots or 
patches of an ecchymotic appearance, observable particularly at the 
points where the formation of false membrane has taken place. 
Another change produced in the pleura by inflammation is the loss of 
its natural polish, which is replaced by a more or less granular and 
rough appearance. In chronic cases it becomes whitish or opaline in 
color, and thickened. It is very rarely softened. 

In addition to the lesions of the pleura itself there are various dis- 
eased products of secretion which require notice. These maybe either 
solid or liquid. The solid products are the false membranes which exist 
so generally in all serous inflammations. They are found both upon 
the costal and pulmonic pleura. In their recent state they are of vari- 
able size and thickness, being in some cases very soft and deposited in 
small points; in others, more extensive, but thin, like paper; and in 
others again thicker (one or two lines in thickness), firmer, and decom- 
posable into several layers. The outer layers are yellow, elastic, and 
soft, while the inner ones are red, more resisting, and marked with 
vascular arborization. When examined some time after their forma- 
tion, the false membranes are found to have been converted into cel- 
lular adhesions, which may be either very loose, or they may fasten the 
lung tightly to the costal pleura. The adhesions are generally, how- 
ever, thin, transparent, and in the form of loose bridles. After a length 
of time, the false membranes come to present the appearances of true 
serous tissue, and like that, are susceptible of inflammation. 

The fluid found in the pleural cavity usually consists of transparent 
or turbid serum, holding albuminous flocculi in suspension. Sometimes, 
but more rarely, it consists of purulent serum, and still more rarely of 
pure pus. The liquid generally occupies the lowest portion of the 
thoracic cavity, but is sometimes circumscribed at various heights, or 
between the lobes of the lung by abnormal adhesions, or by some part 
of the lung which has been rendered incompressible by inflammation. 

The lung presents various alterations from its healthy condition. It 
is pressed backwards towards its root to a greater or less extent. The 
tissue of the organ is generally found in one of two conditions: either 
hard, not crepitating, impenetrable to the finger, and presenting a 
smooth surface when cut into, a state of things which has been expressed 
by the term carnificatioji, and which is a mechanical effect of pressure; 
or else the lower lobe, which is in contact with the fluid, is large, 
heavy, fleshy, rather hard, not so easily penetrable by the finger as in 
simple hepatization, yielding under pressure only a small quantity of 
blood, and but slightly retracted towards the spinal column. The 
latter condition depends in all probability on an effusion which has 
occurred after, or coincidently wnth hepatization. 



SYMPTOMS. 235 

In some cases, in which the effusion is but small, or where it has 
been absorbed, the lung is found to be elastic and crepitating. What- 
ever the amount of effusion may be, it is said that the lung can always 
expand to its normal size if the fluid be absorbed, unless it has been too 
firmly bound down by false adhesions. 

Pleurisy, whether complicated with pulmonic disease or not, is much 
the most frequently confined to one side. In idiopathic cases, it is 
more common on the right than left side; when it accompanies pneu- 
monia, it is, on the contrary, more common on the left than right. 

Symptoms. — In describing the sj^mptoms, we shall treat first of the 
physical, and then of the rational signs, and of the course of the disease. 

The physical signs are exceedingly important, as they often consti- 
tute, especially in young children, the only means of recognizing the 
disease. The pleural friction-sound is less important than some other 
physical signs, as it is scarcely ever heard in children under five years 
of age, and only during the absorption of the fluid, as a general rule, 
in those above that age. Bronchial respiration may commonly be de- 
tected from an early period in the attack. At first it is heard during 
inspiration, but afterwards it exists both during inspiration and expi- 
ration, or in the former alone. In a majority of the cases it is heard 
over the posterior portion of the thorax, and upon one side only. At 
first it is audible over nearly the whole height of the affected side, 
while later in the disease it can be perceived only at the inferior angle 
of the scapula or in the interscapular space. Its duration is variable; 
it may disappear in a few days, or last for a much longer time. In 
favorable cases it is usually replaced by feeble vesicular respiration, 
more rarely b}' friction-sound, and sometimes by pure respiration. 
This sign is almost always present at all ages in acute cases, but is often 
absent in those which are slow and tedious. In suckling children it is 
not constant, but intermits occasionally, so that it may be heard at one 
and not at the next examination. uEgophony can rarely be detected in 
children less than two years old. Under that age, there is heard in- 
stead of it resonance of the cry, especially in the region beneath and 
on a line with the spine of the scapula. It is intermitting, like the bron- 
chial respiration. In children over two years old, segophony can often 
be distinguished by careful examination, but never, of course, unless 
the quantity of effusion is considerable. It is heard at an early period 
of the attack, and chiefly in acute cases, and must be sought for in the 
lower portion of the interscapular space, and the inferior dorsal region. 
It coexists almost invariably with bronchial respiration, lasts but a 
short time, disappearing after one, two, three, or four days, and it is 
intermitting. In older children, it is sometimes replaced by diffused 
resonance of the voice, as it is by resonance of the cry in infimts. In 
a case that occurred to one of ourselves, in a girl between six and seven 
years old, and in which the disease became chronic, the voice was not 
purely segophonic, but reedy and quavering, from the fifth to the tenth 
day. After that date the effusion became so great that all sound was 
suppressed. 



236 PLEURISY. 

Feebleness or absence of the res-piratory murmur seldom exists at the be- 
ginning of acute cases, but in the subacute or chronic form is generally 
present from the invasion. In the latter class of cases feeble respiration 
is noticed first over the inferior portion of the dorsal region, but as the 
effusion increases, it is heard also in the upper and anterior regions, 
and becomes more and more marked, until at length no sound whatever 
is audible; the respiratory murmur is suppressed. In acute cases, on 
the contrary, the absence of the respiratory sound is observed at vari- 
able periods of the attack; when noticed soon after the invasion, it is 
generally coincident with bronchial respiration, which, heard at first 
over the whole or the inferior three-fourths of the dorsal region, be- 
comes afterwards perceptible only in the interscapular space, or at the 
inferior angle of the scapula, while the respiration is feeble or absent 
over the lower portions of the lung. In acute cases the feeble respira- 
tion remains limited to the dorsal region, and disappears after a few 
days, — in from five to eight, according to our experience; while in 
chronic cases it extends over a larger surface, and continues for several 
weeks, or even months. 

Percussion. — This means of diagnosis is very important in all cases 
of the disease accompanied by effusion of liquid, unless the quantity be 
exceedingly small. When, on the contrary, the inflammation results 
merely in the production of thin false membranes, percussion furnishes 
no useful information. 

Percussion is of no assistance, however, at the moment of invasion, 
as it is not until the period at which effusion takes place that the reso- 
nance of the thorax begins to be altered. In acute cases, the resonance 
is generallj^ duller than natural, though seldom entirely dull, on the 
second, third, or fourth day. As the effusion augments, the dulness 
increases over the region occupied by the fluid, until at length all res- 
onance ceases, and the sound is perfectly flat. The degree of dulness 
can be properly appreciated only by comparing the two sides together. 
The degree, extent, and duration of this sign will depend, of course, 
upon that of the effusion. In children, as in adults, the sounds afforded 
by percussion vary with the position of the patient, which influence, of 
course, the situation of the fluid in the pleural cavit}^ 

In regard to the physical signs of pleuro-pneumonia, it maybe stated 
that w4ien a pleuritic effusion takes place in a child laboring under 
pneumonia, it happens, as a general rule, that the bronchial respiration 
occasioned by the inflammation of the lung increases in intensity, 
though in some few cases it is diminished or suppressed. MM. Rilliet 
and Barthez la}^ down the following principle: "That when a 'pleuritic 
effusion occurs in a child affected with hepatization of the inferior portion of 
the hmg, all the abnormal sounds which were perceptible over the diseased 
point are considerably exaggerated, and the sonority disappears." 

Inspection of the thorax affords no assistance at the invasion of the 
disease, nor generally in acute cases which last but a short time, and in 
which the amount of effusion is small. When, however, the effusion is 
large, it may be observed, upon close examination, that the movements 



RATIONAL SYMPTOMS. 237 

of the affected side during respiration are more limited than those of 
the opposite one, and that the intercostal spaces are more projecting 
than natural, in consequence of distension by the fluid within. At the 
same time mensuration will show that the side on which the effusion 
exists is larger than the other. The difference may amount to one- 
third or two-thirds of an inch. In acute cases in which the quantity 
of liquid is small, mensuration will of course show no difference. 

Palpation is an important means of diagnosis, especially in making 
the distinction between pneumonia and pleurisy. In the former dis- 
ease, the vibration of the thoracic walls during either crying or speak- 
ing, is augmented; whilst in the latter it is diminished, or when the 
effusion is considerable, ceases altogether. This sign is important, both 
in infants and older children. 

Eational Symptoms; Course; Duration. — Acute pleurisy is rarely 
met with, as alread}^ stated, in children under six years of age, except 
as a secondary affection. In idiopathic cases it begins with severe pain 
in tiie side, cough, some difficulty of respiration, increased frequency of 
the pulse, loss of appetite, thirst, bilious vomiting, sometimes headache, 
and in rare instances delirium. The^am in the side or stitch is almost 
always present in acute cases occurring in healthy children, while in 
those which are slight, or which occur in weak and debilitated subjects, 
or very young children, it very often cannot be detected. Sometimes, 
however, its existence may be ascertained in very young children by 
tenderness of the side shown during the act of percussion. When pres- 
ent in young children, it can always be detected by watching the face 
of the child and observing its gestures during the act of coughing, and 
during full inspirations, as in those made in crying, after sudden move- 
ment, or in the act of gaping. In an infant of thirteen months old, 
who was attacked with pleurisy of the right side, causing effusion of 
thick j^ellow pus into the right pleural sac, and which ended fatally in 
a month, only the blindest observer could fail to see that every act of 
coughing was acutely painful, for the child uttered each time a short, 
sudden crj^, which was hushed as soon as given, while at the same mo- 
ment there passed across the face an expression, amounting almost to a 
grimace, of suffering, which was unmistakable. The pain is aggravated 
by coughing, by full inspirations, by change of position, and by percus- 
sion. The seat of pain is almost always in front^ but it may extend 
irregularly over the whole of one side to the arm, or it may be con- 
fined to the false ribs, or less frequently to the neighborhood of the 
nipple; it generally lasts from three to six days, though it sometimes 
continues longer. This symptom was complained of in most of the 
cases that we have seen. In some it was very acute and severe for 
one or two days, while in others it was slight, not well defined, and 
very transitory. In one, the child said there was no pain, but a sensa- 
tion of weakness in the side when she coughed. In another, the pain 
was severe for a few hours, but was relieved by a sinapism, and was 
not felt again, though the attack resulted in a very large eff'usion into 
the side. In a third it lasted a week, and in a fourth only two daj^s, 



238 PLEURISY. 

though in both the effusion was extensive, and required several weeks 
for its absorption. In a fifth case it continued for five days. In the 
last, the effusion was very slight. It was aggravated in all these cases 
by coughing, by the act of respiration, especially when this was deep, 
and by motion. 

Covgh exists in nearly all idiopathic cases, and generally from the 
onset, though sometimes not before the second or third day. Usually 
frequent and dry, it commonly retains these characters in acute cases, 
for four or six days, and then diminishes rapidly. In more tedious 
cases it continues for a longer time, but moderates in violence after 
some days. In secondary cases it has no special characters. It was 
present in all but one of the cases seen by ourselves. Its character 
varied very much. In some it was frequent, teasing, and very painful. 
In others it was rare, scarcely troublesome, and only slightly painful. 
In all it was very dry, this constituting one of its most marked features, 
and giving it a very different character from the cough of bronchitis, 
and also, though somewhat less distinctively, from that of pneumonia. 
It continued almost entirely dry throughout the disease, except in a 
case which became complicated after a time with slight bronchial in- 
flammation, and, in that, it became loose. There is generally no expec- 
toration ; if any, it consists of a small amount of whitish, frothy, sero- 
mucous fluid. 

The respiration is usually accelerated in acute cases, but remains 
natural in other respects; the dyspnoea^ however, is slight, as a general 
rule, compared with that of pneumonia. The difficulty of breathing is 
commonly in proportion to the earliness of the age, and to the extent 
and rapidity with which the effasion takes place. In the acute cases 
that came under our own observation, the breathing was usually about 
36, 38, 40, and 48, but in one case it rose to 68 for a single da}'. It was 
not labored, and appeared to be difficult only from the fact of its being 
more or less painful. In a case of double pleurisy that came under our 
observation, it was most laborious, and dreadfully painful, as was also 
the cough. In the cases attended with but slight pain, there was no 
dyspnoea. It usually subsided after two or three days, when large 
effusion took place, converting the case into the chronic form. 

ThQ fever is not usually very great, and seldom lasts more than a few 
days, or a week. In some few cases, however, that we have seen, the 
febrile reaction has been very high. In one, in a child between three 
and four years old, the pulse rose to 172 on the first day, though the 
respiration was but 36; the skin was very hot and dry, and there was 
very great drowsiness and inattention. In other cases the pulse was 
140, 128, and 124. The acceleration of the pulse usually lasts three or 
four days, after which it falls, so that by the end of a week it is seldom 
over 70, 80, or 90. The heat of skin is not very great in most instances, 
and generally subsides rapidly and disappears after a few days. Thus 
during the first few days of the attack, the temperature may rise to 
103° or 104° ; but it soon falls, and, during the remainder of the case, 
usually fluctuates between 100.5° and 102°. When the case is complica- 



CHRONIC PLEURISY. 239 

ted with pneumoDia, the elevation of temperature is even more marked 
and persists for a longer time. In acute secondary attacks, the febrile 
symptoms are more marked, as a general rule, than as has just been 
described, because of the existence of the concurrent disease. 

The countenance -presents no particular characters, except that an ex- 
pression of pain passes across it occasionally when the child coughs, or 
takes a deep breath. It is seldom deeply flushed as in pneumonia. 
The alae nasi are dilated only during the continuance of the difficulty 
of resiDiration. 

The decubitus is generally dorsal or indifferent. In two cases ob- 
served by us, in which the effusion was large, the number of inspira- 
tions was alwaj'S from three to five greater when the child laid on the 
sound, than when on the affected side. 

Headache is often present during the first few days, in children over 
six years of age, and is sometimes very severe. 

Convulsions are said to occur sometimes at the onset in very young 
children. The strength is not usually much diminished, except during 
the acute period. The appetite is diminished and the thirst acute, but 
neither of these symptoms is so marked as in pneumonia. The tongue 
is usually moist, and sometimes covered with a coat of whitish fur; the 
abdomen is natural. 

Bilious vomiting is said to occur in more than half the cases. The 
stools are generally regular, or there is some constipation. 

Auscultation practised soon after the invasion generally reveals rude 
or bronchial respiration without any rales. The percussion is dull. 
The cough, pain, fever, and difficulty of breathing continue for several 
days, after which all but the cough generally disappear, while that com- 
mon 1}^ persists in a mild form. In acute cases, the appetite now begins 
to return, the thirst moderates, and auscultation reveals only feebleness 
of the respiratory murmur, with slight dulness on percussion. The 
general symptoms cease soon after this, and the patient is entirely 
convalescent in from one to three weeks, though feeble respiration and 
diminished resonance sometimes persist for a longer period. 

Urine. — The urine in pleurisy has the so-called febrile characters, but 
usually not in any degree approaching to the urine in pneumonia, the 
water being less diminished, and the urea less increased. In cases where 
there is rapid effusion into the pleura, the chlorides are lessened or 
almost wanting; and reappear as the effusion is absorbed. Albumen is 
scarcely ever present. 

Chronic Pleurisy may follow the acute form, or occur as an idio- 
pathic disease. In the former case, the acute sj^mptoms diminish after 
a variable length of time, but the fever does not cease entirely and often 
recurs towards evening. In the latter case there is usually a very 
moderate degree of fever at first, which soon subsides and then disap- 
pears, or there is none at all; the pain is generally, though not always, 
vaii'ue, uncertain, and attracts but little notice. In one case that we 
attended, the cough was frequent, rather dry, and very painful for the 
first few days, after which it became looser and ceased entirely, though 



240 CHRONIC PLEURISY. 

the inferior two-thirds of the right side were filled with effusion for a 
period of two weeks afterwards. In a second, in which the whole of 
the left side was occupied by the effusion, there was no cough whatever. 
In a third, there was a very slight, infrequent cough during the first 
day, but after that, though the effusion occupied the right side up to 
the spine of the scapula, there was none through the day, and merely 
a little hacking at night. In a fourth, in a girl between four and five 
years old, there was considerable fever during the first week, but liter- 
ally no local symptoms whatever, so that the case was mistaken for 
one of bilious fever by another physician. When it came under our 
notice, some obscurity in the symptoms led us to examine the chest, 
where we found an effusion occupying the lower third of the right side. 
The fever was now diminishing, and soon disappeared, but the effusion 
increased, without pain, and with only an occasional cough, until it 
filled up three-fourths of the side. It then stopped, and after several 
days, began to recede. At the end of about six weeks, the child was 
quite well again, and continues so to this time, about three years. In 
a fifth case, in a boy, between five and six years old, the attack was 
extremely obscure. There was very slight fever, almost no cough, 
indeed none excejDt upon some exertion being made, and then scarcely 
noticeable, and no severe pain. In fact, the child complained of no 
pain whatever, but upon being asked, referred to an uneasy sensation 
in the inferior lateral region of one side. The tongue was coated, and 
the symptoms were rather those of some bilious derangement, than 
of anything more serious. It was not until after four or five days of 
attendance, that a careful examination of the chest showed the exist- 
ence of a slight effusion in the right side. This gradually increased 
until it reached nearly up to the clavicle, and then slowly disappeared 
again. The respiration is somewhat accelerated in all cases, and when 
the effusion is very large, and especially when it is purulent and at- 
tended with violent hectic fever, it is sometimes excessively labored 
and difficult. In the cases that we have seen, however, even when the 
effusion has been very large, the breathing has' not been difiicult. In 
one case it was between 40 and 50 during the first two days, after which 
it fell, as the effusion took place, to 30. In a second it was 4.5 at first ; 
at the end of a week it was 38; at the end of the third week, as the 
effusion was being absorbed, it had fallen to 28, soon after which the 
recovery was completed. In a third it was so slightly disturbed that 
we did not at first suspect any disease of the chest. On the fourteenth 
day, the effusion reaching then nearly to the spine of the scapula, the 
breathing varied between 40 and 28 during sleep, but during the waking 
state there was no visible oppression. 

The effusion takes place gradually, and is generally large. The per- 
cussion is now entirely dull over a greater or less extent of the side, and 
the respiratory sound is suppressed. The side is evidently enlarged, the 
increase of size being visible to the eye and ascertainable by measure- 
ment. If the effusion be purulent, constituting empyema, and the case 
is to end unfavorably, the child emaciates, grows pale, has night-sweats 



DIAGNOSIS. 241 

and hectic fever, and dies at last in a state of profound exhaustion. In 
some cases where the effusion has been at first serous, and later be- 
comes purulent, the development of empyema is clearly indicated by a 
return of elevated temperature, which now persists with very marked 
morning remissions and evening exacerbations. In favorable cases, on 
the contrary, and nearly all those in which the effusion is sero-albumin- 
ous belong to this class, the effusion is gradually absorbed, and the pa- 
tient recovers with a contraction of the side. In some instances the fluid 
has been evacuated by an opening through the parietes of the thorax, 
caused by ulceration or made b}" a surgical operation; and in others 
again b}^ an opening into the lung, through which the fluid has been 
expectorated. In one case that came under our own observation, in 
which the effusion was purulent, a natural cure took place by the 
evacuation of the fluid through an opening in the walls of the chest. 
This case occurred in a very hearty boy, of between four and five years 
of age. He was taken sick in the country, with what was supposed 
to be an attack of typhoid fever. After many weeks of violent ill- 
ness, an abscess showed itself in the neighborhood of the left nipple. 
This, at the end of two months, discharged, and the patient began to 
improve. At the end of three months, he was brought to town, and 
we saw him. AYe found a fistulous orifice, discharging occasionally 
considerable quantities of pus, just below and inside of the left nipple. 
The left side was very much contracted, and the lung was retracted 
into the upper j^art of the chest. He was put upon cod-liver oil, wine, 
and nutritious food, and gradually improved. He was soon removed 
to the country, and we did not see him again, but have since heard 
that he had entirely regained his health. The recovery by absorp- 
tion has been known to take place two and five months after the in- 
vasion. In one case that we saw, the duration from the time when 
the effusion took place to its complete absorption was five weeks; in a 
second it was between six and seven weeks; in a third, six weeks; in a 
fourth, seven; and in a fifth, two months. 

Diagnosis. — Pleurisy may be confounded with pneumonia or hydro- 
thorax. From the latter affection it is to be distinguished by the ab- 
sence of pain in that disease, by the existence of the effusion on both 
sides of the thorax in most cases, and by the fact that hydrothorax 
generall}^ follows as a consequence of some previous disease, particu- 
larly the eruptive fevers or nephritis. 

The distinction between acute pleurisy and lobar pneumonia is more 
difficult than that between pleurisy and hydrothorax, and in some in- 
stances is subject to considerable doubt. It may generally be arrived 
at, however, by attention to the differences laid down in the following 
table, which is taken from the Eibliotheque du Medecin Practicien : 

ACUTE IDIOPATHIC PLEURISY. ACUTE IDIOPATHIC PNEUMONIA. 

Frequent after six years of age ; rare Frequent after six years of age ; more 
under thiat age. rare under that age, but much less so than 

pleurisy. 

16 



242 PLEURISY. 



ACUTE IDIOPATHIC PLEURISY. ACUTE IDIOPATHIC PNEUMONIA. 

Begins with dry cough, sharp thoracic Begins with cough, slight thoracic 
pain, hronchial and metallic respiration pain, and crepitant or subcrepitant rhon- 
during inspiration, either on the first day chus ; at a later period there is bronchial 
or later, and more rarely with obscurity respiration during the expiration and 
of the respiratory sound. bronchophony. 

Modification of the physical signs by No modification under like circum- 
change of position. stances. 

Fever and acceleration of the respira- Fever violent ; considerable accelera- 
tion usually moderate. Rapid diminution tion of the respiration. Diminution of 
of these symptoms from the fourth to the these symptoms less marked, less rapid, 
seventh day. and not before the sixth or ninth day. 

Expectoration absent or very slight. Expectoration mucous ; sometimes san- 

guineous ; very rarely rust-colored. 

No rhonchi. Rhonchi preceding, following, and 

often accompanying the bronchial respi- 
ration. 

Absence of vibration of the thoracic Augmentation of vocal resonance very 
parietes during speaking or crying. sensible in older children, and in a less 

degree in all. 

Course of the disease irregular ; rapid Course of the disease regular ; steadily 
disappearance in some cases, prolonged increasing in most cases, and then dimin- 
duration in others. The bronchial respi- ishing from the sixth or ninth day. Bron- 
ration is substituted or masked by feeble chial respiration more disseminated, 
respiration. 

In some cases, especially in young children, where the onset of pleu- 
risy is very sudden and acute, the general febrile disturbance may en- 
tirely mask the local symptoms, and lead to the belief that some one 
of the exanthemata is about to develop itself. 

Thus we have met with cases where, in the midst of full health, the 
child has been seized with violent fever; extreme restlessness alternat- 
ing with stupor; repeated vomiting; great frequency of pulse; accel- 
eration of respiration; but with little or no cough and no complaint 
of pain in the side. In one instance of this kind, the heat of skin, 
rapidity of pulse, and frequency of the vomiting were so marked that 
for twenty-four hours we suspected the approach of scarlet fever, and 
not until the second day were we able to satisfy ourselves of the nature 
of the attack by observing that the act of respiration was evidently 
painful, and by detecting the physical signs of plastic pleurisy over 
the right apex posteriorly. 

In 2 cases, one at the age of 3 months, the other at 1 J years, we have 
observed most excessive and almost tetaniform reflex irritability, so 
that the slightest movement of the child's body, or the attempt to ex- 
amine the chest, would provoke violent startings and spasmodic con- 
tractions of the entire body. In both of these cases a fatal result 
followed, and post-mortem examination revealed the presence of local- 
ized empyema. 

The chronic form of .pleurisy with extensive effusion may be easily 
distinguished by the history of the case, by inspection, palpation, and 
mensuration of the chest, by the nearly total absence of sonority, and 
of the respiratory murmur except at the inner edge of the scapula, 
and by attention to the character of the general symptoms. 



PROGNOSIS — TREATMENT. 243 

Prognosis. — Acute pleurisy is rarely a fatal disease in healthy sub- 
jects. "When it occurs as a complication of some other malady, on the 
contrary, it is much more a})t to terminate unfavorably. The degree 
of fotality in secondary cases will depend, of course, in great measure, 
on that of the primary disease. Pleuro-pneumonia is a more dangerous 
disorder than either alone. Of 5 eases of primary- pleuro-pneumonia, 
observed by Eilliet and Barthez, 2 died; while of 10 secondary cases, 8 
died. 

Of the 28 cases of pleurisy that we have seen, 5 died. The 5 fatal cases 
were all primary; 4 of them occurred in infants, 2 at 6 weeks, and the 
others at 13 and 18 months respectively, and the fifth was a case of 
double pleurisy in a boy betvveen 4 and 5 jears old. Of the 23 children 
that recovered, one was betw^een 1 and 2 years of age; one between 2 
and 3; three between 3 and 4; while eight were between 4 and 5 years 
of age, and the remainder over that age. In our experience, therefore,! 
the mortality was, as might have been expected, much greater in those 
cases occurring at a very earlj^ age. 

Chronic pleurisy is generally a serious, and not unfrequently a fatal 
disease, though since the more frequent and more skilful use of para- 
centesis many cases are cured which would formerly have proved fatal. 

Treatment. — The hygienic treatment in this, as indeed in all the dis- 
eases of children, is of the utmost importance, and ought to be regu- 
lated by the practitioner himself. In all forms of the disease, the child 
should be carefully protected from cold, and in the acute form, kept at 
rest, and, if possible, in bed. The diet must be very strict, and should 
consist for a few daj'S of the preparations of milk. After the fever has 
disappeared, bread and milk, vegetable soup with a few oysters boiled 
in it to make it agreeable, and gradually rice, potatoes, and at last 
small quantities of meat, may be allowed. In the chronic form the 
diet ought to be nutritious, but regulated with equal care as to quan- 
tity and material. In that form the patient should be taken into the 
air if the w^eather be mild and dry, and in winter the chamber ought 
to be w^ell aired from time to time. 

Bloodletting. — In acute cases occurring in vigorous children over five 
years of age, marked by intense fever and pain in the side, and which 
are seen soon after the onset, local depletion may be employed. The 
amount of blood to be taken should not exceed two or three ounces; 
and this should be w^ithdrawn by small cups applied over the seat of 
inflammation. In younger children, as well as in all whose constitu- 
tions are not robust, it is better to limit ourselves to the use of a few 
dry cups. 

Depletion in any form ought to be avoided in most of the secondary 
cases, unless the symptoms are very acute and the child strong and 
vigorous; also in all chronic cases, after the febrile symptoms have 
been dissipated, and in feeble, delicate children. 

Antimonials — Febrifuges — Opiates. — A moderate use of the antimo- 
nials is of great service in the acute stage of the disease. Small doses 
of antimonial wine and sweet spirit of nitre, or fractional doses of sul- 
phurated antimony, as recommended in the article on pneumonia, will 



24i PLEURISY. 

generally cause the fever, dyspnoea, and cough to subside rapidly. 
Large doses are unnecessary in any case, and are liable to be injurious 
in all. 

In cases in which antiraonials ought not to be used, as where they are 
opposed by some idiosyncrasy, in children of low vital force, and in the 
secondary form of the disease, we have found a citrate of potash mix- 
ture, containing ipecacuanha and opium, and digitalis, when the heart is 
much excited, very useful. The quantity of opium must be proportioned 
to the pain. When this is severe, the doses must be full. The good 
effects of this remedy in serous inflammations are now generally ac- 
knowledged. At two years of age, one drop of laudanutn in the above 
mixture, every two hours; or half a grain of Dover's powder, with the 
tw^elfth of a grain of sulphurated antimony, every two hours, until a 
decidedly tranquillizing effect is obtained, may be used. When posi- 
tive drowsiness has been brought about, the doses ought to be given 
at longer intervals — every three or four hours. 

Mercury. — In former years mercury was constantly employed in con- 
junction with bloodletting. In our last edition we opposed its use as 
unnecessary in acute cases, but stated that there was high authority 
for employing it in cases of the acute form tending towards the chronic, 
and in confirmed chronic cases; adding, however, that we had not 
found it necessary even in these. We find, now, that Dr. West, of 
London, still speaks highly of it. He says {loc. ciY., p. 303) : "After 
depletion, our chief reliance is to be placed on calomel, which should 
be freely giv^en in combination with opium or Dover's powder; and an 
attack of pleurisy thus treated will often be cut off in thirty-six or 
forty-eight hours." Dr. J. Lewis Smith, of New York {loc. cit., p. 279), 
does not even mention mercury in his remarks on treatment. Dr. 
Thomas Hillier (Diseases of Children, Amer. ed., 18G9, p. 87) says : 
" Formerlj" I gave mercury to all cases of primarj^ pleurisy, but this 
practice 1 have discontinued, except in the form of an aperient. In- 
stead of it, salines, such as acetate of ammonia, nitrate of potash or 
soda, the citrate of potash, and nitrous ether, are given." 

The experience we have had, since we last wrote, has not at all in- 
creased our faith in this remedy. We believe that as time goes on, and 
knowledge grows, there is good reason to think that the good effects 
formerly ascribed to calomel in such a variety of diseases, were largely 
due to the medicines given with it, and particularly the opium (without 
which it was not often used), the ipecacuanha, the salines, and even the 
antimonials. 

The remedies employed by ourselves^ after the disappearance of the 
acute symptoms, when the effusion has taken place, and especially if 
there seems any tendency for the case to pass into the chronic form, 
are either iodide of potassium in syrup of sarsaparilla, according to the 
following formula: 

R. — Potass. lodidi, gr. xvj ad xxxij. 

Syrup. Sarsap. Comp., 

Aquae, aa, f^j. — M. 

Dose, a teaspoonful three times a day ; 



TREATMENT. 245 

or the syrnp of the iodide of iron, of which from thirty to sixty drops 
should be substituted for the iodide of potassium in such a mixture as 
the above. The iodide of potassium is preferable in the early stao;e. 
After a time, and especially in an?emieal and delicate patients, the 
iodide of iron should be substituted. Under this treatment, combined 
with the application of a Burg-undy pitch plaster to the side, or some 
other form of counter-irritant, the effusion has usually disappeared in 
from two to eight weeks, though diuretics may have failed to make 
any impression on the cases. 

Diuretics are highly recommended in the treatment of cases in which 
effusion has taken place. Those chiefly emplo3'ed are squills, digitalis, 
and nitre. The squill is given alone, or in combination with digitalis, 
and by some with calomel, or with both. The dose of the powder of 
squill or digitalis, is about a quarter of a grain every two or three 
hours. The squill may be used also in the form of syrup or oxymel, 
and the digitalis in tincture. These two substances may be employed 
in the following formula : 

R.— Acet. Soillffi, f^ij. 

Tinct. Digitalis, ........ gt xxx. 

Aquae Fluvial, f^iv. — M. 

Of this a teaspoonful is to be given three or four times a day to chil- 
dren two years old. This formula was made use of for several days in 
two of the cases referred to, without any perceptible diminution in the 
amount of the effusion, whereupon it was suspended, and the iodide of 
potassium, and afterwards the iodide of iron, as above recommended, 
substituted, and with much better effect. 

Purgatives ought to be used during the acute stage of pleurisy to an 
extent sufficient to keep the bowels soluble, and to act as mild evacu- 
ants. In chronic cases, on the contrary, ihaj are particularly recom- 
mended as evacuants, in order to deplete the bloodvessels, and thus 
hasten the absorption of the effusion. So far as our experience goes, 
this treatment is unnecessary^, as diuretics and alterative tonics are 
generally suflScient, without a resort to violent remedies, which must 
irritate the intestinal mucous membrane, always extremely susceptible 
in children, to a dangerous degree. 

Tonics are often necessary in chronic, and sometimes, after the feb- 
rile symptoms have subsided, in acute cases occurring in feeble and 
delioate children. The most suitable are quinine, in the dose of a grain 
morning and evening, small quantities of port wine^ and the prepara- 
tions of iron. 

External Remedies. — Blisters are very generally employed, in the 
acute form, to relieve pain and dyspnoea, and, in the chronic, to hasten 
the absorption of the effused liquid. We did not appl}^ them in the 
cases under our charge, having succeeded very well without; but 
would not hesitate to make use of a small one, applied for a not longer 
period than two hours, if the pain and oppression persisted. In chronic 
pleurisy the application of a large Burgundy pitch plaster, made rather 
weaker than what is used for adults, and large enough to cover nearly 



246 PLEURISY. 

the whole side, would be preferable to blisters. "We are also in the 
habit of painting the chest-wall, over the seat of the effusion, with di- 
lute tincture of iodine, every day, or as frequently as the irritability of 
the skin will permit. The following mixture is of about the proper 
strength for a young child : 

R.— Tr. lodinii, f^iij. 

Chloroform, ....... f^j. 

Alcoholis, . f^iv.— M. 

Paracentesis. — Of late years, the operation of paracentesis, in cases of 
pleurisy, both acute and chronic, has been performed so frequently, and 
with such encouraging results, that it may now be considered to occupy 
an assured position among the remedies for certain conditions of this 
disease. It appears desirable, therefore, to discuss somewhat in detail 
the circumstances in which it is a^^plicable, the indications which call 
for it, and to a certain extent the mode of its performance. In doing 
this, we shall avail ourselves freely of the admirable and exhaustive 
discussion of this operation by the lamented Trousseau {Clinique Medi- 
cale, torn, i, pp. 619-698), to whose practice and teaching it was in 
great part due that paracentesis thoracis was first generally recog- 
nized as a justifiable operation for the relief of excessive pleuritic effu- 
sions. 

In acute pleurisy he recommended the operation more frequently than 
most authorities consider necessary. Whenever, indeed, the effusion 
becomes so excessive as to almost entirely fill the pleural sac on the 
affected side, displacing the adjacent viscera seriously, whether the 
patient presents intense dyspnoea or not, he advises its performance. 
The reasons urged b}' him for this practice were, that although ordinary 
cases of acute pleurisy almost invariably recover, yet when such exces- 
sive effusion exists, it may prove fatal in more than one way. It has 
not very rarely happened that, from the obstruction to respiration, 
conjoined with the embarrassment of the heart's action due to its 
twisting and dislocation, death has occurred suddenly; and we have 
met with the records of several cases in children which had this un- 
fortunate and unexpected termination. 

Again, in these cases of excessive serous effusion, if the fluid be not 
removed either by absorption or paracentesis, there is great danger that 
the case will be converted into one of empyema, not from the actual 
conversion of the serum into pus, but from the altered condition of 
the secretion from the pleural surface. 

But even when the fluid does not become thus converted into pus, 
but remains clear and serous, absorption is very slow, and the patient 
may perish from exhaustion and hectic fever. During the long time 
necessarily occupied in the absorption of the fluid also, the pleurisy 
really becomes less and less curable, since the lung contracts such close 
and dense adhesions as prevent it from ever fully expanding again. 
Finally, if any tuberculous diathesis exists, the long course of the 
pleuritic attack favors very greatly the development of phthisis. 

The chief objections which have been urged against the performance 
of paracentesis in these acute cases are that the effusion will form again 



TREATMENT — PARACENTESIS. 247 

rapidly, requiring repeated punctures and exhausting the patient; that 
the operation prolongs the duration of the case; and that there is 
danger of converting the serous effusion into a purulent one. 

In regard to the first of these, however, experience has shown that 
in many cases a single puncture is suflScient, and that even when the 
fluid does reaccumulate, it is rarely to such an extent as to demand a 
repetition of the operation. 

There is, again, no reason for supposing that the puncture, if properly 
performed, can in any way tend to prolong the case. In regard to the 
last objection, the cases recorded sufficiently show that if care be taken 
to prevent the admission of air, there is not much reason to apprehend 
the conversion of a serous into a purulent collection, unless the consti- 
tutional condition is so impaired that in all probability the case would 
have passed into one of extensive empyema, had the operation not been 
performed at all. Indeed, it is proved by the direct experiments of 
Nysten and Hewson, that air injected into the pleural cavity does not 
the least harm to the serous membrane. 

Since the recent introduction of the greatly improved apparatus for 
performing paracentesis, also, this source of danger is to a great extent 
removed. By means of Bowditch's instrument, or better still, by one 
of Dieulafoy's aspirators, the effusion can be withdrawn through a 
canula so fine that its puncture scarcely creates the slightest irritation, 
and at the same time with entire exclusion of air. In this manner, 
paracentesis has been performed repeatedly of late years, even in the 
acute stage of pleurisy, without being followed by any of the unfavor- 
able results formerly so much dreaded. 

In view of the various risks incurred in cases of excessive hydro- 
thorax. Trousseau thus sums up his remarks upon the operation: 
"Whenever auscultation and percussion reveal the presence of a very 
large effusion, whether its formation has been attended with acute 
symptoms or not, which interferes seriously with respiration, even 
\ though dj'spnoea is not marked; and when this effusion tends to in- 
crease, despite the active employment of local and general remedies 
for nine or ten days, the operation is indicated." He especially directs 
attention to the fact that the mere amount of dyspnoea must not be 
taken as a guide, since this may be absent, although there are at the 
same time evidences of grave interference with the oxidation of the 
blood. If, however, during the existence of such an effusion, spells of 
suffocative dyspnoea should ensue, or syncopal attacks, the operation is 
urgently called for. 

In the London Hospital Reports for 1865, these views are warmly ad- 
vocated and powerfully supported by Dr. Fraser, who believes that the 
operation should be more generally employed than at present. 

We have already alluded to the fact that occasionally an extensive 
effusion will remain serous for a long time, but in the majority of cases, 
and especially in children, it sooner or later becomes transformed into 
pus. Indeed, so frequently does this occur, that West expresses his 
conviction that in every case of idiopathic pleuris}- in childhood, in 
which fluid is poured out in considerable quantity, the effusion is either 



248 PLEURISY. 

orio;inal]y purulent or becomes so very specdil}^. In these unfortunate 
cases, where there is little or no disposition to absorption, where marked 
hectic fever and exhausting night-sweats soon set in and rapidly debili- 
tate the patient, and where the most favorable result that can be hoped 
for is that the pus will either evacuate itself externall}^ or open into 
the lung and be expectorated, the operation of paracentesis should be 
undoubtedly performed. 

It is evident, indeed, that paracentesis must here have many advan- 
tages, since in cases where the pus discharges externally spontaneously, 
it is almost invariably about the fourth intercostal space, and outside 
of the nipple, at a point therefore which renders it impossible for the 
pus to freely evacuate itself, and which thus tends to keep open the 
fistula for a very long time. Again, it not rarely happens in these 
cases that the fistula does not lead directly into the pleural cavity, but 
that the pus has burrowed in the thoracic walls, leading to denudation 
and necrosis of the ribs or sternum. 

The termination by the establishment of a pulmonary fistula, and the 
evacuation of the pus through the bronchial tubes, is a comparatively 
favorable one, but yet the case is apt to be more tedious, and certainly 
the lung tissue must be much more seriously affected than when a free 
exit is given to the matter by the operation of paracentesis. In these 
cases, of course, the effusion will almost certainly form again, and 
either require repeated punctures, or a fistula will be established, 
through which pus will discharge almost daily. 

In addition to the advantage afforded by relieving the system of this 
source of irritation, and giving the lung a chance to expand, paracen- 
tesis enables us also to introduce medicated fluids into the thorax, and 
thus to modify the diseased pleural surface. We will detail below the 
injections which appear to us most useful for this purpose. 

Although, even under the most favorable circumstances, empyema is 
a most dangerous and not rarely fatal affection, numbers of cases are on 
record in which life has been undoubtedly saved by a recourse to this 
operation, and it has been noticed that the proportion of success is 
much greater in cases of children than of adults. Thus, out of J 6 cases 
in childhood, 13 of which occurred in West's practice, no less than 35 
terminated favorably, there being one death in every 4 cases. 

In a recent paper by M. Guinier, of Montpellier (^Bull. de VAead. de 
Med., t. XXX, p. 645; Bien. Retrospect of New Syd. Soc, 1865-6, p. 152), 
the particulars of 31 cases from different authors are recorded. The 
patients were of all ages up to 14 years; as many as 16, however, were 
in their 7th, 8th, or 9th year. In one of his own cases, a rapid recovery 
was effected in a case of extensive sero-purulent pleural effusion in a 
nursing child one year old. The mortality was about 1 in 6; and in no 
instance does the operation appear to have done any harm, but, on the 
other hand, seems to have relieved suffering and retarded death even 
in the fatal cases. 

One reason of this greater success in early life possibly is, that the 
much greater mobility of the chest-walls in children allows a rapid 
contraction of the thorax to occur after the pus has been withdrawn, 



TREATMENT — PARACENTESIS. 249 

SO that the chest-wall comes in contact with the lung, which, in 
such cases, is always bound down by dense and strong adhesions; 
whereas, in adults, the more unyielding character of the thoi'ax main- 
tains a space between the two layers of pleura for a much longer time. 
On the other hand, it must be evident that this same greater mobility 
of the chest-walls will enable an excessive pleural effusion to be toler- 
ated more readih", and with less injui'ious effect upon the thoracic 
organs, than can occur in the comparatively rigid adult chest. 

The great deformity of the thorax which ensues upon empyema in 
childhood is rarely permanent, but as the lung slowly expands, the 
thoracic walls gradually regain their normal shape, the depression of 
the shoulder disappears, and in the course of a few j^ears at the farthest, 
scarcely any trace of distortion or contraction remains. 

Our own opinion in regard to the propriety of this operation, and 
the indications for its performance, is as follows : in ordinary cases of 
pleurisy in children, with moderate effusion, it is unnecessary. When 
the effusion is very extensive, and causes marked displacement of the 
heart, distension of the affected side, and severe disturbance of breath- 
ing, the question of operating should alwaj^s be raised, and, if, after 
consultation with the parents, it is determined upon in case of necessity, 
all preparations for its performance should be made, and we should 
hold ourselves in readiness to perform it immediately on the appearance 
of urgent symptoms. Still so long as there is no reason to dread that 
the case is passing into the stage of empyema, we should recommend 
a faithful trial for several weeks of the internal remedies, especially 
digitalis and iodide of potassium, and of the local use of repeated ap- 
plications of dilute tincture of iodine. In many cases where the effu- 
sion has been thus extensive and of quite long standing, we have thus 
obtained speedy and complete cures, without deformity of the thorax. 
If, however, positive reduction in the amount of effusion did not soon 
begin to show itself, we would unhesitatingly operate. Finally, in all 
cases where the symptoms lead us to conclude that the effusion is more 
or less purulent, the duty of immediate operation is an imperative one. 

In regard to the performance of the operation itself, the chief source 
of difficult}^ lies in the necessity of excluding air; though this precau- 
tion is only necessary in cases of serous effusion, since where paracente- 
sis is performed for empyema it almost invariably happens that sooner 
or later the pleural sac communicates with the external air. 

The procedure recommended by Trousseau is as follows : The patient 
being placed near the edge of the bed in a semi-recumbent posture, his 
body steadied by an assistant, a small incision is made through the 
skin in the sixth or seventh intercostal space, a little outside the line 
of the external border of the pectoralis major. An ordinary trocar, the 
canula of which is protected by a valve of goldbeater's skin, thin gutta- 
percha, or a piece of animal membrane of any kind, is then placed in 
this wound and thrust boldly into the pleural cavit}^, the precaution 
being taken of grasping the instrument so that not more than one inch 
shall be free, to avoid all possibility of wounding the lung. 

It is preferable, we think, if a simple trocar and canula be used, that 



250 PLEURISY. 

a piece of narrow india-rubber tubing should be attached to the, end of 
the canula, and that the trocar should be passed through from the out- 
side of the tube close to the canula, so that after the puncture into the 
chest has been made, the trocar may be withdrawn, when the little hole 
in the elastic tube will close and prevent any entrance of air. The free 
end of the india-rubber tubing should be carried under the surface of some 
water placed in a vessel intended to receive the effusion as it escapes. 
Thus we can simply but surely effect the withdrawal of the fluid without 
permitting the entrance of air. The same result may be attained by 
the use of a Bowditch's syringe or one of Dieulafoy's aspirators, which 
act on the principle of a syringe, to be attached to the canula after its 
introduction through the chest-wall and the withdrawal of the trocar, 
and so constructed that when the piston is drawn out the barrel is 
filled with fluid sucked from the chest, but when it is pushed home 
again, a valve closes the communication with the canula and opens a 
lateral outlet through which the fluid is forced. Another improve- 
ment in the details of this operation, which has a great influence upon 
the degree of irritation caused by it, is the use of a very small canula 
for making the puncture. 

It is necessary that the thrust given to the trocar should be fearless 
and quick, since if it be pushed in a hesitating way, the point may push 
before it the layers of false membrane which probably coat the pleura, 
and the effusion will not be reached. Should this accident occur, an 
attempt may be made to break through the false membrane by a probe 
introduced through the canula, or a second puncture must be made in 
a different place. 

Difterent opinions exist in regard to the advisability of withdrawing 
the entire effusion at once, but experience has, we believe, shown that 
no unfortunate results need be apprehended from so doing. The last 
portions of fluid which escape are apt to be stained with blood, probably 
from rupture of the delicate new-formed vessels of the false adhesions. 

The dressing of the wound should be as simple as possible, consisting 
merely of closing the incision by a piece of adhesive plaster, over which 
a pledget of lint may be secured by a bandage round the thorax. 

Almost the only unpleasant symptom which follows the removal of 
the fluid is spasmodic cough, w^hich often comes on in severe, and at 
times painful paroxysms. Syncope is scarcely ever noticed, if the pa- 
tient be kept in a state of absolute rest after the operation. The inter- 
nal remedies, especially the diuretics, should be continued, and Trous- 
seau recommends, what we have also found useful, that the side should 
be painted with tincture of iodine. 

When we have reason to believe that the effusion is purulent, which, 
as we have already remarked, is very frequently the case in childhood, 
there are some points of difference in the operation. Thus we can have 
no hope that the effusion will not form again, and either require a sec- 
ond operation, or, as frequently happens, cause the cicatrix of the first 
puncture to re-open. Again, before the case is brought to a successful 
termination, it is often necessary to employ some medicated injections 
to alter the character and secretion of the pleural surfaces. 



TREATMENT — PARACENTESIS. 251 

It is doubtful, therefore, whether the admission of a small quantit}^ of 
air is very objectionable, although West believes that it almost ahvays 
converts the previous healthy pus into a highly offensive sero-purulent 
discharge. The ill effects of this can be overcome by the injections to 
be recommended below ; but. on the other hand, care must be taken 
not to admit so much air as would interfere with the expansion of the 
lung. It is advisable on the whole, however, to perform the first punc- 
ture with the same care, and to employ the same dressing as in the case 
of serous effusion. But if a second puncture is required, or if the first 
one re-opens, the wound should be enlarged so as to admit a good-sized 
canula, which should be allowed to remain. This canula should be of 
silver, curved so that its extremity may not come in contact with the 
gradually expanding lung; and its shield should be furnished with a 
ring of caoutchouc, placed between the instrument and the skin, to pre- 
vent excoriation. 

After the pus has been withdrawn, the pleural cavity may be washed 
out through the canula with tepid water, and then there may be in- 
jected about an ounce of a mixture of 1 part of tincture of iodine to 
from 4 to 7 parts of tepid water, effected by the aid of a little iodide of 
potassium. 

The canula should then be closed by a cork, and not disturbed for 
twenty-four hours, when the accumulated pus should be withdrawn, 
and a second injection practiced. In the first injections it is better 
probablj^ to allow the iodine solution to run out again ; but after we 
have assured ourselves of its effect, it may be allowed to remain. 
Throughout the continuance of the treatment the pus should be allowed 
to escape at least once every day, though as the secretion diminishes 
the iodine injections may be practised only at longer intervals, as once 
in two, three, or four days. The effects of these injections are usually 
very beneficial; they correct the fetor of the discharge, diminish its 
amount, aud never, so far as we are aware, are productive of pain or 
increased inflammation. In cases where they appear to have lost their 
good effects, other agents may be substituted, as weak solutions of car- 
bolic acid, chlorinated soda, or aromatic wine. 

In cases which terminate favorably, the discharge diminishes gradu- 
ally, though often ver}^ slowly, the chest contracts, and finally there is 
nothing left but a fistula, which for a short time discharges a few drops 
of serous pus before healing. As an example of the tolerance to this 
treatment shown even by young children, and of the good results finally 
obtained in many desperate cases, we would refer the reader to the ex- 
traordinary case recorded at length in Trousseau's Clinique Medicale 
(t. i, pp. 650-52), where, in a boy of 6 years, the canula was allowed to 
remain for eleven months, during which time medicated injections were 
constantly employed. The amount of pus discharged in all is estimated 
by Trousseau as not less than 80 pounds, and yet perfect recovery 
finally ensued, and at the date of the report the child's health was ex- 
cellent. 

During the course of such cases, every attention must be paid to sus- 



252 PLEURISY. 

tainins^ the child's nutrition by abundant nourishing food, stimulus, if 
needful, bitter tonics, iron, and cod-liver oil. 

We subjoin the following case to illustrate the remarks we have 
made upon the treatment of pleurisy, and to show the importance of 
faithfully employing suitable internal remedies before resorting to par- 
acentesis, in cases where the effusion is serous and not so excessive as 
to seriously embarrass respiration. 

Case of chronic pleurisy of the left sir/e, beginnivg with acute symptoms; extensive 
effusion, vn/h displaceTnent of the heart to the right of the sternum : recovery. — The 
subjf'ct of the case was a boy four years old, of delicate stature and appearance, 
"but enjoyino; o;ood health. We saw him first at 1 p.m. on February 12th. He was 
perfectl}^ well the day previous, slept soundly durino; the night, and rose apparently 
in good health in the morning. He ate his usual breakfast but complained after- 
wards of feeling unwell. Soon after this he complained of headache, of soreness and 
weakness in the knees in going up stairs, and then of violent pain in the left side 
beneath the armpit. 

At the time of our visit, he was in bed, in the following condition: pulse 130, full 
and strong; skin warm and moist; headache; sharp, severe pain at the prsecordia, 
extending backwards under the armpit, and aggravated by motion, crying, and by 
deep inspirations; respiration quick and jerking. No cough at all; absolutely none. 
Abdomen natural ; neither vomiting nor diarrhoea Tongue slightly furred and 
moist. Action of heart violent; impulse strong and felt over a large space; sounds 
loud and strong; to the left, and bpneath the nipple, a soft murmur with the second 
sound. Percussion dull over a larger space than natural. 

Behind, percussion dull over whole of leftside; natural on right side. Eespira- 
tion natural on the right side; feeble and indistinct, without bronchial sound, on the 
left. 

Ordpred a teaspoonful, each, of extract of senna and syrup of rhubarb, to be given 
immediately ; to have a warm bath in the evening, and to take one of the following 
powders every two or three hours, beginning in the evening: 

R. — Pulv. Opii et Ipecac, gr. iij. 

Potass. Nitrat., ...... gr. vj. 

M., et. div, in chart, no. vi. 

February 18. Passed a restless night. Better to-day. Pulse 130; softer; skin 
moist. Impulse of heart less violent. Pain not so severe. Eespiration still quick, 
and when the child is excited or irritated, it becomes jerking, while at other times it 
is quiet. Physical signs as before, except that the murmur, with the second sound 
of the heart, is no longer heard. Ordered three ounces of blood to be drawn by 
leeches from the left side ; powders to be continued so as to allay restlessness and 
pain. 

February 14. Has had a better night. Pulse less frequent. Eespiration 30, and 
without jerking ; no cough at all ; makes no complaints of pain. The appetite is 
returning. 

February 15. Better in all respects; no fever nor pain ; no cough. Physical signs 
as before. 

The case went on until the 27th of March, when we paid our last visit, making the 
whole duration of the case over six weeks. During the last two weeks of February, 
there were no acute symptoms. The fever had disappeared entirely. The respiration 
continued, however, from 28 to 30 during all that time. The effusion occupied nearly 
the whole of the left side, which was manifestly larger than the right, and the intercostal 
spaces were protruded. Behind, there was total flatness on percussion, from the spine 
of the scapula downwards, and in front from a short distance beneath the clavicle. The 
respiratory niurmur was absent in the lower three-fourths of the dorsal region, and 
feeble above. In front, respiration was heard only above and just beneath the clavicle. 
In the course of this period the heart was gradually forced over to the right side of the 



PNEUMOTHORAX. 253 

sternum, so that at last its impulse was felt, not to the left, but to the right of that 
bone. The cardiac sounds were loudest and most distinct in the same region. The 
displacement was so remarkable that the mother discovered it herself, as we had 
avoided telling her to save her from anxiety. The new position of the heart did not 
seem to produce any inconvenience in addition to that occasioned by the pleuritic 
effusion. During the last two weeks of March the child was kept in bed ; his diet 
was milk and bread; a large Burgundy pitch plaster was kept on the side, and he 
took internally, vinegar of squill and tincture of digitalis. 

Finding that the effusion remained stationary under this treatment, we prescribed 
a grain of iodide of potassium three times a day, in a teaspoonful of compound syrup 
of sarsaparilla. The diet was changed at the same time. He was allowed small 
quantities of meat every day, and was taken from bed and placed in a chair by the 
window. Under this treatment he gradually improved, so that by the 27th of March, 
when we paid our last visit, the effusion had in great measure disappeared, and he 
was able to play about the room all day. The side was slightly contracted ; the 
respiration was pure and vesicular, but rather more feeble than on the left side ; the 
heart had returned to its natural position. 

We examined this child six years later, and found him to be in excellent health. 
Excepting a slight contraction of the left side, there was no perceptible difference 
between that side and the right. 



AETICLE YL 



PNEUMOTHORAX. 



In this condition there is an accumulation of air in one or both pleural 
cavities. The source of this air is either from without, when there is 
an opening through the chest-wall; or from the bronchial tubes, when 
there is perforation of the pulmonary pleura. There are a certain 
number of cases recorded, in which it is supposed by the authors that 
a secretion of gas has occurred from the pleural surface, or that it has 
been directly developed from the decomposition of some inflamma- 
tory eflPusion in the pleural cavity; but the evidence upon which the 
possibility of such occurrences rests is insufficient, and for clinical pur- 
poses, at least, it may be assumed that where pneumothorax exists, 
there has invariably been some communication established between the 
pleural cavity and the atmospheric air. It is, therefore, to be regarded 
not so much as a distinct disease, as a complication of manj^ other 
pathological conditions. There are peculiarities, both as to the cause 
and symptoms of this condition as it occurs in childhood, which render 
a separate account of it desirable. It is, however, certainly compara- 
tively infrequent in children, owing in part to the rarit}^ of the injuries 
and wounds, which often cause traumatic pneumothorax in adults; and 
in part to the fact that the diseases, especially empyema and tuber- 
culosis with the formation of vomicae, which are the most frequent 
causes of it in adults, are either less frequently attended with this 
complication in children, or are of comparatively rare occurrence. 



254 PNEUMOTHORAX. 

Anatomical Appearances : PDeumothorax may be found to exist on 
both sides, but as a mere pathological condition which, of course, must 
have produced death immediately. It is nearly always limited to one 
pleural sac, and before the thorax is opened, the affected side is observed 
to be distended, with prominent intercostal spaces. The percussion- 
phenomena, which will be hereafter described, persist, and it is some- 
times possible by rapidly moving the body, while the ear is placed in 
contact with the chest, to develop a succussion-splash. If a small 
opening be made through an intercostal space, the compressed air will 
often be heard escaping with a hissing sound, and occasionally the cur- 
rent has so much force as to extinguish a lighted candle held near the 
opening. The air which escapes is usually, but not always, of offensive 
odor, in consequence of being tainted by the decomposition of the 
pleuritic effusion which is apt to coexist. If the entrance of air has 
followed a penetrating wound of the chest, or a compound fracture of 
the ribs, the familiar appearance of these lesions will be found. More 
frequently it has depended upon perforation of the pulmonary pleura, 
in consequence of some morbid action, and we may then detect the 
spot of perforation, and study its characters, by filling the chest with 
water and blowing through a tube into the trachea, when a stream of 
air-bubbles will be seen to rise through the fluid from the point of aper- 
ture, unless this has been obstructed by layers of false membrane. 
The lung itself will be found more or less extensively collapsed, accord- 
ing to the nature of the lesion which has caused the perforation. It can 
rarely be inflated completely in consequence of the free escape of air 
through the pleural opening. The adjacent movable viscera are dis- 
placed by the pressure of the gaseous collection^ even to a greater 
extent than in many cases of hj'drothorax. The position of the per- 
foration in the pleura varies, but is most frequently found at some 
part of the middle lobes, or the adjacent parts of the upper and lower 
lobes. We have, however, found two points of rupture in one case, 
both seated near the apex. The opening itself is usually rounded, or 
occasionally lenticular; in size it varies from one to three lines in 
diameter. The edges of the pleura are thin, and often softened and 
discolored. There may be but a single point of perforation, or several 
may coexist, either grouped closely together over an abscess of consid- 
erable size, or scattered over the surface of the lung (as in the case on 
the following page), each opening corresponding to a distinct abscess. 

The condition of the lung varies exceedingly, and, of course, presents 
the appearances proper to the lesion which has caused the pneumo- 
thorax. Thus there will be found in about the following order of fre- 
quencj^, the appearances, elsewhere described in their appropriate 
places, of tuberculosis of the lungs (either in the form of softening 
subpleural miliary formations, or of small superficial vomicae); of small 
superficial abscesses resulting from lobular pneumonia; of circumscribed 
apoplexy or gangrene of the lung; or of vesicular and interlobular 
emphysema with subpleural bullaa. In most cases, there are evidences 
of pleurisy associated, and the pleural cavity contains a variable quan- 
tity of fluid, either turbid or bloody serum, or ichorous pus; and^ at the 



ANATOMICAL APPEARANCES. 255 

same time, the surfaces of the pleura may present patches or organized 
layers of lymph. Of course, these appearances will be most marked 
in cases where the perforation of the pleura has resulted in consequence 
of a previous empyema. In other cases, the fluids found in the pleu- 
ral sac have in part escaped from the lung-tissue through the perfora- 
tion, and are in part due to the pleuritic inflammation superinduced. 
The irritation caused bj^ the mere admission of air into a healthy 
pleural sac is not always sufficient to excite inflammation, and thus in 
rare cases, where pneumothorax results from the rupture of an emphy- 
sematous bulla, the pleura may present no inflammatory exudation 
whatever. But in the great majority of cases, either from the fact 
that pleurisy coexists, or that there is an escape of j^us from the lung 
at the time of jDcrforation, the pleura presents the appearances above 
described. It occasionally happens that, owing to the previous exist- 
ence of pleuritic adhesions over a part of the lung, the escaping air ig 
circumscribed, and produces only a local pneumothorax. In such 
cases, of course, all the alterations of the thorax, as well as the atten- 
dant physical signs, are limited to the seat of the gaseous collection, 
and may, indeed, be associated with the evidences of chronic pleurisy, 
with retraction of the remaining parts of the chest. In still other 
cases, although the pleura has been perforated, the escape of air is en- 
tirely prevented by the existence of adhesions of the pleura over the 
point of rupture; or, as in the interesting case reported on page 222, 
by the close apposition of enlarged bronchial glands. 

The following case, which, owing to the absence of any clinical his- 
tory, possesses chiefly an anatomical interest, may be given, as showing 
the usual conditions of a pneumothorax dependent upon pneumonia. 

Case. — Partial Suppurative Pneumonia : Superficial Abscesses^ with Suhpleural Em- 
physema : Perforations of the Pleura : Pneumothorax: Miliary Tuberculosis. — Mary 
McC, aged 13 months, died February 11th, 1868, after a short illness, during 
which the most marked symptoms were dyspnoea and cough, with occasional vom- 
iting. At the autopsy, there were all the physical signs present of pneumothorax 
of the left side. The right lung was found congested and partially collapsed, but 
admitted of complete inflation. In the posterior part of the fissure between the 
upper and middle lobes, the upper lobe presented a separation of the pleura from 
the lung to the extent of half an inch in diameter. On the apposed portion of the 
lower lobe there was a similar large bulla. The lung-tissue immediately subjacent 
to these cavities was consolidated to a distance of an eighth of an inch. On cut- 
ting into the bullae, they were found to be distended with air and dark sanious pus, 
and their cavities presented minute trabeculge and septa, consisting of bronchioles 
and the remains of ruptured air-vesicles. There evidently was no gangrene of the 
lung-tissue, so that it appeared that these lesions had resulted from a combination of 
patches of. suppurative pneumonia of the superficial layer of the lung with suh- 
pleural emphysema ; and it seemed reasonable to conclude from the unusual relations 
of the emphysematous bullae, that they were due to the process of softening which 
had opened a connection between some of the terminal bronchioles, and the suh- 
pleural connective tissue. There were scattered miliary tubercles in the upper lobe. 

The left lung presented two similar but larger bullse (fully one inch in diameter), 
in exactly the corresponding position between the upper and lower lobes. There was 
a small perforation of the pleura in the one in the upper lobe. Two other similar but 
smaller cavities were found on the surface of the lower lobe, in each of which the 



256 PNEUMOTHORAX. 

separated pleura presented a perforation about one-sixth of an inch in diameter. 
There were traces of localized pleurisy in the neighborhood, but no adhesions; and a 
considerable pneumothorax had resulted, causing collapse of at least one-half of the 
lung. 

The bronchial glands, spleen, and kidneys contained miliary tubercles. There was 
no decomposition of the tissues. 

Causes. — Although, as already stated, pneumothorax is a compara- 
tively rare disease in children, it will be found, when present, to occur 
most frequently in 3'oung children (under the age of 5 years), and espe- 
cially in those of feeble constitution. The causes which directly lead 
to its development vary greatly in their relative frequency, as compared 
with the causes of pneumothorax in the adult. 

Thus we find that the most fruitful cause of pneumothorax in chil- 
dren is unquestionably tuberculosis of the lungs. In adults this con- 
dition leads to perforation of the pleura usually only after the produc- 
tion of a vomica; but, in children, excavation of the lung-tissue to any 
extent is rare in tuberculosis^ and when it does occur is quite constantly 
associated with such close adhesions of the neighboring pleural surfaces, 
as would effectually prevent the escape of any air into the pleural cav- 
ity, even in event of a perforation of the walls of the cavity. It is 
found, therefore, that pneumothorax more frequently results from the 
softening of small superficial tubercles, which involve the pleura and 
lead to its softening and perforation. 

The next most fruitful cause of pneumothorax in children is probably 
pneumonia, when it passes on to the stage of suppuration with the 
formation of a superficial abscess, w^hicli seems most likely to haj^pen 
when the inflammation occurs in a localized and circumscribed form. 
The three cases with which we have ourselves met were all due to this 
cause. It is probable that this unfortunate termination is much more 
frequent in secondary pneumonias (especially those following such 
diseases as measles, or, as in one of our cases, severe remittent fever), 
and, in a number of the cases, miliary tubercles have been found associ- 
ated, as in the instance quoted above by us. In such cases the plastic 
exudation formed on the pleural surface is often too small to prevent 
the escape of air after the perforation has occurred. 

Gangrene of the lung and the softening of superficial patches of pul- 
monary apoplexy, are mentioned by several authors, particularly by 
Killiet and Barthez, as following next in order of frequency. But, ac- 
cording to our own observation, empyema, with consequent ulceration 
of the pleura and communication with the bronchi, although not so 
frequent a cause of pneumothorax in children as in adults, yet furnishes 
more cases than either of the former rare conditions. Occasionally, 
also, when the purulent fluid in empyema has discharged itself exter- 
nally by an ulcerated opening in an intercostal space, air has found en- 
trance to the pleural cavity, and produced a pyo-pneumothorax. 

Finally, pneumothorax has been known to follow the rupture of a 
subpleural bulla in cases of interlobular emphj^sema. It is especially 
in such cases that the collection of air may be found without any coex- 



SYMPTOMS. 257 

isting" liquid effusion. It is probable, however, that were life to be 
prolonged after such an occurrence, some pleural inflammation would 
be established, and lead to serous eifusion. 

In most cases the actual perforation of the pleura is the result of the 
progress of the pulmonary disease which has ultimately involved the 
serous membrane in its course; but it is probable that the rupture may 
be at times precipitated by any violent eff'ort, particularly by a fit of 
coughing or severe vomiting. 

Symptoms. — In some cases where the antecedent disease is a very 
grave one, and the strength of the child is greatly reduced, the super- 
vention of pneumothorax is with difficulty detected, and death occurs 
from the sudden increase of obstruction to the respiration before an 
opportunity is afforded for careful examination. 

The occurrence of the perforation is often marked b}^ an abrupt and 
decided increase of the dyspnoea which has already existed in conse- 
quence of the preceding disease. It will, however, be readily under- 
stood that this increase in oppression is not of such constant occurrence 
in children as in adults, owing to the fact that in the former all acute. 
diseases of the chest are apt to be attended with an extreme degree of 
dyspnoea. So, too, the sharp lancinating pain usually complained of 
b}^ adults at the time of the development of pneumothorax may be 
latent, or only revealed by increased agitation and more hurried, shal- 
low breathing. In some of the r cases, Eilliet and Barthez observed a 
cough which they considered peculiar, and described as "short, fre- 
quent, jerking, painful or convulsive, and sharp or piercing;" and a 
similar cough has been noticed by other observers. 

In cases where death does not occur very quickly, and where a care- 
ful examination of the chest can be secured, the physical signs of pneu- 
mothorax are much more characteristic than the general s^miptoms. 
The affected side is distended, and its intercostal spaces bulge slightly. 
The respiratory movements are overactive on the opposite side to atone 
for the marked impairment of motion of the affected one. Percussion 
over the seat of the pneumothorax gives either merely exaggerated 
resonance, or a tympanitic or amphoric sound. Frequently this mor- 
bid resonance will be found associated with dulness upon percussion in 
some parts of the thorax, owing to the coexistence of consolidation of 
the lung or of pleuritic effusion. It may also happen that if the dis- 
tension of the affected side be extreme, the tympanitic resonance will 
grow more or less flat, owing to the overtension of the thoracic walls. 
According to the condition of the lung and the character of the open- 
ing in the pleura, the respiratory murmur may be absent, or be present 
as metallic bronchial breathing, or more frequently as pure amphoric 
breathing. The vocal fremitus has generally been found decidedly 
diminished. Metallic tinkling has been detected in several instances; it 
was observed by Barrier to be most distinct during the effort at cough- 
ing. We are not aware that a splashing sound, such as can so fre- 
quently be developed in cases of pneumothorax in the adult, by succus- 
sion, has yet been observed in children. 

17 



258 PNEUMOTHORAX. 

The adjacent movable viscera are found to be displaced bv the 
pressure of the gaseous accumulation, especially in left-sided pneumo- 
thorax, where the dislocation of the heart to the right is very marked. 
Of course, if the j^neumothorax be circumscribed, the above physical 
signs will be limited to the same spot. 

It will thus be seen that the symptoms of this condition in children 
closely resemble those which it presents in the adult; but that in many 
cases it is impossible, owing to the great agitation of the child, to fully 
deirionstrate their existence. 

Course — Prognosis. — The course of pneumothorax in children is 
usually a rapid one. Occurring as it does, as a complication of some 
serious pre-existing disease of the lung, it so increases the respiratory 
embarrassment as to generally induce death in from a few hours to a 
few days. In rare instances only is life prolonged for a few weeks. 
The prognosis, although regarded by Eilliet and Barthez as, on the 
whole, less unfavorable than in the same condition in adults, is still 
exceedingly grave, both from the serious character of the condition 
itself and from the grave nature of the diseases (tuberculosis, secondary 
pneumonia, gangrene of the lung, interlobular emphysema.) in whose 
course it occurs as a complication. Eilliet and Barthez observed one 
case where recovery ensued after the positive signs of pneumothorax 
had persisted for twenty days in a boy 3 years of age. They regarded 
the case as originally one of pneumonia. 

We have also observed a case, in a boy 11 years old, during an at- 
tack of secondary pneumonia, complicating a severe bilious remittent 
fever, where complete recovery ensued, though after a most violent 
illness -, and it would indeed seem that, with the exception of the com- 
paratively rare traumatic cases, the prognosis of pneumothorax in chil- 
dren is most fiivorable when it occurs in this connection. 

Steffen (^Klinik d. Kinderkrankheiten, bd. i, p. 137, et al.) expresses this 
opinion also, and places as the next most favorable variety that which 
is associated with empyema. Although it might be expected that 
pneumothorax resulting from the rupture of emphysematous bullae 
w^ould be of favorable prognosis, on account of the trifling amount of 
pleural inflammation which often attends that lesion, the fact is that 
this condition of the lungs themselves is so serious that a fatal result 
has followed in all cases so far recorded. 

In regard to the diagnosis^ it is quite true that the occurrence of 
pneumothorax in the course of one of the thoracic diseases which we 
have seen it may complicate is apt to be overlooked, either owing to 
the want of symptoms definite enough to arouse suspicion of the devel- 
opment of some new lesion, or to the difliculty of securing a careful 
physical examination of the chest. When, however, this physical ex- 
ploration is made with the frequency and care which are demanded 
in every case of acute thoracic disease, especially when threatening 
symptoms exist, the characteristic physical signs will be determined, 
and can scarcely be attributed to any other than the true cause. 

Treatment. — The management of pneumothorax must be considered 



HOOPING-COUGH. 259 

alwavs with reference to the primary disease which it complicates, and 
its occurrence must not be allowed to interfere with the prosecution of 
the treatment necessary for this. As it is evident, however, that this 
additional lesion will still further tax the vital powers, and as the'-only 
chance of recovery lies in maintaining life till the cause, if curable, is re- 
moved and the air absorbed, we would advise that all remedies capable 
of reducing the strength or disturbing nutrition should be discarded, 
and that by every means the system should be sustained. In addition, 
we should recommend the moderate use of sedatives — either in the 
form of the preparations of opium or byoscyamus, associated with 
bromide of ammonium if the cough be very severe and paroxysmal, to 
quiet agitation and excessive dyspnoea, and to relieve the cough. If 
the distension of the affected side and the pressure on the surrounding 
organs be great, and the evidences of impeded circulation and oxidation 
of the blood are threatening, recourse may be had to puncture through 
an intercostal space with a very fine trocar. Although the results of this 
operation must be regarded as palliative rather than curative in most 
cases, yet as the paracentesis itself is attended with no danger, its per- 
formance is to be recommended whenever the signs of pressure from 
the accumulation of air in the pleural sac become alarming. It is es- 
pecially in cases where there is a liquid effusion associated with the gas 
(constituting a hydro- or pyo-pnenmothorax) that paracentesis will 
afford most relief. In one case of this kind, Hennig performed para- 
centesis, evacuating a large amount of purulent liquid and gas, with 
very great relief to the symptoms of oppression. The child, a boy of 
4 years of age, lived four weeks after the operation, and then sank 
from exhaustion. 



AETICLE VII. 

HOOPING-COUGH, OR PERTUSSIS. 

Definition; Synonyms; Frequency. — Hooping-cough is character- 
ized by a hard, convulsive cough, occurring during expiration, and 
accompanied by long, shrill, and laborious inspirations, which are 
called hoops. The cough occurs in paroxysms, which are terminated 
by the expectoration of tough phlegm, and often by vomiting. 

The disease is known by various other names, of which the most 
common are tussis ferina, chincough, and kincough. The frequency of 
the disease is exceedingly variable, as it occurs both in the sporadic 
form and as a widely-prevailing epidemic. Some idea of its frequency 
may be gained from the facts that, during the five years from 1844 to 
1848, inclusive, there were 390 deaths from it in Philadelphia, under 
15 years of age, out of a total mortality of 31,162. .During the five 



260 HOOPING-COUGH. 

years from IBG-t to 1868 inclusive, there were, out of a total mortal- 
ity of 76,854, 543 deaths from hooping-cough; a proportion consider- 
ably smaller than that during the first period of five years above men- 
tioned. The irregularity is even more strikingly seen bj' comparing 
single years with each other: thus, while in 1867, there were but 65 
deaths from this cause, there were no less than 208 in 1862. 

Causes — Age. — It occurs generally in children, and may be met 
with in the first weeks of life; indeed, Watson in bis lectures, men- 
tions a case where the mother, during the last week of her pregnancy, 
lived in a house where the disease was prevalent, and her infant 
hooped the very day it was born. Of 208 cases in children, in our 
own private practice, 26 occurred in the first 3^ear of life, 147 between 
the ages of 1 and 7 years, and 35 between 7 and 12 years. To be more 
explicit, we will state that of 188 cases in which the age was accurately 
noted, 11 occurred in the first six months of life; 9 between 6 and 12 
months; 30 in the second year; 17 in the third, 32 in ihe fourth, 17 in 
the fifth, 30 in the sixth, 16 in the seventh, 13 in the eighth, 8 in the 
ninth, 3 in the tenth, and 1 in the eleventh and twelfth years of life 
each. Of 130 cases in children, collected by M. Blache, 106 occurred 
between 1 and 7 years of age, and only 24 between 8 and 14. Of 29 
eases observed by MM. Eilliet and Barthez, there were 26 between 1 
and 7 years, and 3 between 8 and 12. It is stated by MM. Blache, 
Eilliet and Barthez, and Yalleix, to be most common in girls. Of 208 
cases observed by ourselves, 106 occurred in boys, and 102 in girls. 
Some writers have asserted that certain constitutions and hertdttary in- 
fluence predispose to the disease. So far as our own experience goes, 
it has seemed to attack indifferentl}^ those who were simultaneously 
exposed to it. The fact of its being propagated by direct contagion is 
proved beyond doubt by numerous observations. We have rarely 
known one child in a family to be attacked without its extending to 
all the others not protected by having had the disease previously. 
That it often appears also in the form of an epidemic^ is established by 
the testimony of many writers, so that at present no doubt is enter- 
tained upon this point. 

Symptoms. — It is customary to describe three stages of hooping- 
cough. The first is called the stage of invasion, or the catarrhal 
stage; the second the stage of increase, or the spasmodic stage; and 
the third the stage of decline, which is characterized by an amendment 
of all the symptoms. 

First Stage. — The great majority of the cases begin with the ordi- 
nary symptoms of simple catarrh. These are coryza, sneezing, slight 
injection of the conjunctivae, and dry cough. The cough rarelj^ has any 
peculiarity in the beginning which will enable us to distinguish it from 
that of an ordinary cold, though some persons have asserted that they 
could recognize it. We have often listened with great care to the 
sound of coughs which parents supposed might be hooping-cough, but 
were always obliged to confess our inability to determine, until time 
gave them more decided characters. In addition to the symptoms 



SYMPTOMS. 261 

enumerated, there is generally more lano-uor, lassitude, drowsiness, 
and irritability, than are commonly present in simple catarrh. In a 
small proportion of cases the first stage is wanting, and the disease 
assumes its peculiar features from the first. The duration of this stage 
is very uncertain, and is ascertained with difficulty. Our own ex])eri- 
ence would fix it at about two weeks as the average, though it may 
last undoubtedly a much shorter or longer period. The earliest period 
at which we have known the distinctive hoop of the disease to be heard 
was in three days. In another ease it was five days. We have also 
known it to appear at a later period than usual. In a good many in- 
stances it has been as late as three weeks, but very rarely hiter, 

St'cond Stage. — At the beginning of this stage the disease has assumed 
its peculiar convulsive and paroxysmal character. It consists of vio- 
lent fits or paroxysms, or as they are often called, kinks of cough, 
recurring after longer or shorter intervals. Just before the paroxysm 
the child seems restless, anxious, and irritable, or else keeps perfectly 
quiet and evidently tries to retard its approach. When it begins, the 
child, if lying down, rises up suddenly, or if playing about runs to take 
hold of some fixed object, by which to support itself during the acces- 
sion. The cough is dry, spasmodic, and sonorous, and occurs in a suc- 
cession of short, rapid expirations, by which the thorax seems to be 
em|)tied of all its air with violent efforts. It is followed by one or 
two long and deep inspirations, which are accompanied by the peculiar 
hoop to which the disease owes its name, and which is caused by the 
drawing of the air rapidly and forcibly through the narrowed glottis, 
which is spasmodicall}^ closed. During the fit the face becomes deeply 
suffused or even purple, and swollen; the eyes are watery, and the 
countenance is expressive of great anxiety, and after the fit is over, of 
fatigue and exhaustion. The latter symptoms are, as M. Yalleix 
remarks, the signs of partial asphyxia, and are the result doubtless of 
the complete expulsion of air from the thorax, and a consequent par- 
tial suspension of the function of hsematosis. There is almost always 
an expectoration of colorless ropy fluid, often accompanied by vomit- 
ing, at the close of the fit of coughing, and the patients usually appear 
weak and languid for a short time, after which they return to their 
play. 

In very severe cases there are other symptoms in addition to those 
just mentioned. Hemorrhages from the mouth, ears, nose, lungs, and 
beneath the conjunctivae, are not unusual. We have ourselves seen 
several instances of epistaxis, one of effusion into the eyelids, a few 
of extensive subconjunctival ecchymosis, and we are well acquainted 
Avith the history of another case, in which there was bleeding both 
from the nose and ears. In one case, in a girl between five and six 
years old, that occurred to one of ourselves, in which the paroxysms 
were violent, the spells were accompanied in the latter half of the fourth 
and in the fifth week, by a discharge of a good deal of blood from the 
mouth. This took place particularly during the night-spells, so that 
in the morning the basin would contain several teaspoonfuls of blood. 



262 HOOPING-COUGH. 

It was not from the nose. It was bright in color, pure, except that it 
was intermingled with sero-mucoiis expectoration, but it was not inti- 
mately blended with the sputa, nor was it streaked through the mucus 
as it sometimes is in the pneumonia of children. On one occasion it 
was seen to fly from the mouth in a little spirt, as though from a vessel. 
The child was lively and well all this time, playing about, eating well, 
strong, not thirsty, without pain, not oppressed between the spells, 
and sleeping naturally between the paroxysms at night. The only 
altered physical sign was slight dulness on percussion over the upper 
part of the right lung behind, with some subcrepitantrale at that point, 
but without bronchial respiration. After lasting twelve days, it ceased; 
the child got well gradually, and continues strong and hearty to the 
present time. In another case, in a girl two years of age, which came 
under our own observation, a species of syncope, a state of insensibility 
without convulsive movements, accompanied by great paleness, oc- 
curred after many of the paroxysms. 

We have met with general convulsions in 12 cases, 5 of which proved 
fatal. In 2 other cases, both occurring in infants under six months, the 
paroxysms of cough were accompanied by the most violent struggling 
and oppression, and by deep blueness of the hands and feet, like that 
of severe cyanosis. 

In some instances, after the paroxysm is apparently over, the child 
will begin within a few instants to cough again, and may in this way 
have several fits in such rapid succession as to make an almost continu- 
ous parox3'sm. It is quite common for this to happen twice, and in 
one case which we saw, it occurred three times on several occasions. 
The ordinary duration of a paroxysm or kink, is from a quarter to three- 
quarters of a minute, though it may last as long as two minutes, or ac- 
cording to some even longer. In a case that occurred to ourselves, one 
paroxysm lasted the extraordinary period of fifty-five minutes. That 
it was really a paroxysm of the disease, we are quite sure, as it chanced 
that we reached the house shortly after it began, and witnessed the 
greater part of it ourselves. The number of accessions in twenty-four 
hours is ver}^ irregular. It depends chiefly on the stage and violence 
of the attack. During the height of the disease, we have generally 
found them to number about 40. In some rare cases, however, they 
are much more numerous, and amount to 70 or 80. They are generally 
most frequent in the course of the third or fourth week, after which 
they remain stationary as to frequency for several days, or for two or 
three weeks, and then decline gradually. The paroxysms may occur 
spontaneously, the child being often disturbed from sleep by their sudden 
occurrence, or they may be excited by various circumstances, such for 
instance as contrarieties, a fit of crj'ing, change of position, eating, 
violent exercise, and imitation. We have frequently seen an attack 
brought on by the sight of another child in a paroxysm of the disease. 
The duration of the second stage may be stated to be about 30 or 40 
days in most cases. 

Third Stage. — It is impossible to fix a precise limit from which to date 



COxMPLICATIONS — CONVULSIONS. 263 

the beo'inning of this stage. It is generally, however, said to commence 
from the time Avhen the disease is evidentl}^ on the decline. The par- 
oxysms now grow less frequent and less violent, the cough reassumes 
some of the catarrhal features which it had at first, and gradually loses 
its peculiar spasmodic character. The child's general health improves, 
the appetite becomes vigorous, the strength is invigorated, the sleep 
again becomes sound and tranquil, and the disease disappears. The du~ 
ration of this stage is uncertain, like that of the two others. MM. Eilliet 
and Barthez state it to be- short in uncomplicated cases (ten to fifteen 
days), and are of opinion that when it has been supposed to have lasted 
several weeks or months, it has been the result of some complication, 
as chronic dilatation of the bronchia, tubercular disease, &c. It 
happens not unfrequently, however, that after the disease has a])par- 
ently ceased, all the distinctive characters of the cough recur, if th& 
child chance to take cold within a few weeks or even longer after its 
disappearance. 

In cases of pertussis unaccompanied by complications of any kind; 
there are no marked general symptoms. There is seldom any fever, the 
appetite continues good, and with the exception of occasional languor 
and fatigue, and irritability of temper, the child appears to be well. 

Urine. — Xo accurate analyses of the urine in pertussis appear to have 
been made. Gibb and Johnston, however, state that they have found 
sugar in variable quantities in almost every case. This question ap- 
pears well worthy of full investigation, since, if this statement is con- 
firmed, it would link itself in the most interesting manner with the 
other evidences in this disease of irritation of the pneumogastric nerves, 
which are at least somewhat concerned in the glycogenic function of 
the liver. 

The total duration of the disease, in simple cases, may be set down at 
from one to three months. We have never known a case to last so 
short a time as a month, and have rarely found the whole duration 
much within three months. 

Complications. — Though it has happened to us, on several occasions, 
to meet with children who have been very ill fi'om the violence of the 
disease under consideration in its uncomplicated condition, we have 
never known a case to prove fatal except in consequence of some kind 
of complication. It is exceedingly important, therefore, that the vari- 
ous accidents apt to occur in the course of the disease should be care- 
fully considered. 

Convulsions. — This complication is not a rare one, since it occurred 
in 5 of 29 cases observed by MM. Eilliet and Barthez, and in 12 of 208 
observed by ourselves. It is one of the most dangerous accidents liable 
to occur in the course of the disease. Of the 7 cases reported by the- 
authors quoted (5 of their own, and 2 belonging to M. Papavoine), 6^. 
died. Of our 12 cases, 5 died. In all that we have seen, the convul- 
sions were general, extremely violent, and accompanied by insensibility 
in the fatal cases to the last, and in the favorable ones, during from a- 
few minutes to half an hour. In two of the fatal eases the pertussis^ 



264 HOOPING-COUGH. 

had lasted nearly two months, and was accompanied by extensive 
bronchitis. The fatal event took place within twenty-four hours from 
the supervention of the spasms. The subjects were eight and nine 
months of age respectively. In the third case, the convulsions came 
on in the seventh week of the disease, in a child who had been labor- 
ing for a number of days under bronchitis. They ended fatally in seven 
hours. In the fourth they occurred in a child in the second year of its 
age, at the end of about four weeks, proved fatal in two days, and were 
caused by bronchitis and collapse of the lung-tissue. In the fifth case 
they occurred likewise in a child in the second year of life, were at- 
tended with violent laryngismus and contraction, and proved fatal in 
the third week of the disease. 

One of the favorable cases occurred in a child five months old, who 
had been attacked with bronchitis three days before the occurrence of 
the convulsions, which came on during the height of a severe paroxj^sm 
of coughing. The convulsive movements were general, and continued 
for about half an hour, after which the child was drowsy or irritable 
for some hours longer. The hooping-cough continued to be severe for 
two weeks after this, as many as 42, 46, and 48 paroxysms occurring 
every day. At last, however, perfect recovery took place. The second 
favorable case w^as that of a girl between two and three years old, in 
whom a convulsion occurred in the third week of the disease, before 
the paroxysms had become violent, and evidently in consequence of an 
attack of fever dependent upon dentition. The seizure lasted only a 
few minutes, was followed by drowsiness for a few hours, but on the 
following day all the unpleasant symptoms had disappeared. In a 
third case, in a boy between two and three years old, a violent convul- 
sion occurred at the end of the second week, at the beginning of an 
attack of pneumonia. The child remained very ill, and nine days 
afterwards had another convulsion, which was much slighter than the 
first. After this he gradually recovered. In a fourth case, in a girl 
between two and three years old, a slight but well-marked convulsion 
occurred at the onset of an attack of bronchitis, w^hich took place at 
the beginning of the third week of the hooping-cough. The bronchitis 
proved to be very severe, but there was no return of the spasm, and 
the child recovered. In a fifth case, in a boy nine months old, a severe 
fit occurred in the sixth week, just after the child had been brought 
home from an expedition to procure his daguerreotype. It lasted fifteen 
minutes, and was attended with total insensibility, and purple discolor- 
ation of the face, but in half an hour after, the patient was nursing 
well, and was entirely conscious. There was no return of the convul- 
sions, though the disease was very severe after this attack. In the 
sixth case, also in a boy nine months old, a slight convulsion occurred 
during one of the paroxysms in the fifth week, but was not followed by 
any bad consequences. 

Amongst the complications ought to be ranked, we think, though 
this has not generally been done by writers, an excessive degree of the 
laryngismus which constitutes one of the natural and essential features 



COLLAPSE OF THE LUNG-TISSUE. 



26o 



of the disease. In some children, in fact, and especially in those of a 
nervous temperament, and in the anemical and debilitated, and, like- 
wise, in certain epidemic types of the disease, this laryngismus assumes 
a degree of severity which is not only distressing but positively dan- 
gerous. In one case that occurred to ourselves, in a child who had 
sutfered many months before from laryngismus and contracture, the 
occurrence of hooping-cough reproduced the laryngismus, and after a 
few weeks caused death almost instantaneously, at the beginning of a 
paroxysm, as the child was sitting upon the floor, where it had been 
placed only a few moments before to play, it having presented before 
this no very threatening sj^mptoms. In another case, in which we 
could detect no other complication, the spasm of the glottis was so very 
violent, that after a few daj's the spells were attended with convulsions, 
and very soon ended fatally. In a third, this s^^mptom was so violent 
that in many of the spells the child ceased for the time to bi-eathe, 
seemed to faint, became entirel}' unconscious, and had to be fanned and 
carried to an open window to be revived; this patient ultimately re- 
covered. In a great many cases, this symptom, without other complica- 
tion, has been most distressing, and has required particular treatment. 

Collapse of the Lung-Tissue. — The recent discoveries in regard to the 
pathological change in the pulmonary tissue called collapse, and especi- 
ally a consideration of the causes by which collapse is produced, might 
Avell lead us to suppose that pertussis, and especially the bronchitis of 
pertussis, would be very apt to become associated with collapse. Late 
researches accordingly show that of all the lesions met with in hooping- 
cough this is much the most frequent and important. Dr. Graily 
Hewitt, of London, in a lecture on the pathology of hooping-cough, 
read before the Harveian Society of London, in 1855, shows '^ that the 
catarrhal inflammation of the bronchial tubes, which occasions hooping- 
cough, is, in fatal cases, attended almost universally with collapse of 
the lungs." He states that his observations were made upon nineteen 
subjects, whose age varied from four years to one month, the average 
beiiig eighteen months. '*In all, the state of the lungs was carefully 
noted. The chief lesion found after death was collapse of the lung- 
substance. The following is a statement of the degree to which this 
pathological condition manifested itself in the diff'erent lobes of the two 
lungs. 

"In the right lung, portions of the upper lobe were found collapsed in 
six cases, and in four more to a less degree. The middle lobe was col- 
lapsed, wholly or in part, in sixteen cases. The lower lobe was more 
or less afl'ected with collapse, in eighteen cases. In the left lung, the 
upper lobe presented the same lesion in fifteen cases, the whole of the 
anterior tongue-like prolongation being in most of the cases affected. 
The lower lobe was collapsed more or less in eighteen cases. In seven 
of the cases, the portions collapsed were also congested, in some to a 
high degree. 

"The test of MM. Bailly and Legendre, viz., the inflatability of the 
portions of the lung thus afl'ected, was used in almost all the cases; 



266 HOOPING-COUGH. 

and on that and other grounds, it was determined, that the particular 
part of the lung in question was collapsed and not hepatized. 

"It will be at once perceived, that the occurrence of collapse was 
almost universal; all the cases, with the exception of one, in which 
there was extensive tuberculization of the lungs, presenting a greater 
or less amount of lung-substance affected in this manner,'' 

We have had but few opportunities of testing this matter for our- 
selves by post-mortem examinations ; but in one case to which we were 
called in consultation, that of a boy not quite a year old, this lesion 
was shown, by autopsy, to be present to a great extent. The child had 
had the disease during three months with considerable severity. He 
was thought to be doing well, until he was taken one day a long drive 
into the country. After the ride he seemed very much fatigued, and 
that night was seized with very great dyspnoea, increased violence of 
the coughing spells, and after a short time w4th general convulsions. 
We saw him on the following day. He was breathing very rapidly 
and with much eflPort, there was a good deal of subcrepitant rale through 
the chest, the skin was cool, and about the mouth had a cyanotic tint, 
and he was unconscious. The same symptoms persisted through the 
day with occasional convulsive seizures, and on the following day he 
died. At the autopsy, there was found very extensive collapse of both 
lungs, as proved both by the anatomical appearances, and by inflation. 
There was no pneumonia, and very moderate bronchitis. 

Bronchitis has always been supposed to be the most frequent compli- 
cation of hooping-cough, and there can be no doubt that it is one of the 
most important. The recent discoveries of the existence and nature of 
collapse have shown, however, that many of the fatal cases, hitherto 
ascribed to bronchitis, or to bronchitis and pneumonia combined, must 
have been cases of collapse, so that large allowances must be made for 
all statistics collected before the discovery of the true nature of the 
last-named lesion. 

There is, as has already been stated, a certain amount of pulmonary 
catarrh in every case of hooping-cough. This is a normal element of 
the disease. To constitute a complication there must be a true bron- 
chitis, an inflammation of the bronchial mucous membrane, sufiicient 
to produce the ordinary symptoms of that disease. This exists in a 
great many cases ; MM. Eilliet and Barthez found it to exist cither 
alone or combined with pneumonia in half of the fatal cases. Of the 
208 cases observed by ourselves, it existed to a greater or less extent 
in 42. In 28 of these it was mild or only moderately severe^ and of 
these all but one recovered. In 14 it was severe and very extensive, or 
else capillary, and of these 6 died. Of the fatal cases, it was in several 
no doubt attended with collapse of the lung-tissue. In fatal cases, it 
has often been found accompanied by continuous dilatation of the 
smaller bronchia. 

Pneumonia, according to the authors above quoted, is about as fre- 
quent as bronchitis. When, however, the fatal termination took place 
soon after the beginning of the disease (18th, 26th, or 27th daj^s) it was 



SEQUELiE — DIAGNOSIS. 267 

not generally present. After these periods, on the contrary, it was 
almost always observed. As these authors, however, include under the 
title of lobular pneumonia, many cases of bronchitis with coHapse, it is 
clear that a large number of their cases of supposed pneumonia ought 
to have been ranged under the head of bronchitis. For our own part, 
we have met with onh^ five well-marked cases of pneumonia. Two of 
these occurred in girls of seven and nine ja^ars old respectively, one in 
a girl between one and two years of age, a fourth in a boy between 
two and three years old, and a fifth in a boy in his ninth year. They 
all recovered. The degree of danger from this complication is in pro- 
portion to the earliness of the age at which the disease occurs, and to 
the extent of the inflammation. 

Emphysema undoubtedlj^ follows or accompanies hooping-cough in 
some cases. In a considerable proportion of ftxtal cases the lesions of 
vesicular, and, less frequently, of interlobular emphysema are discovered. 
These will be found described in full in our article upon the latter 
affection, where we have also alluded to the rare occurrence of emphy- 
sema of the subcutaneous tissue of the neck, and even of the entire 
body, as a consequence of the free escape of air into the connective 
tissue of the lung, and thence into the mediastinal spaces. It is, there- 
fore, probable that, in cases of pertussis which end favorably, but in 
which the paroxysms of cough have been severe, a less degree of em- 
physema occurs, which in most instances speedily passes away after 
the disappearance of the primary aflPection. Indeed, as nearly all the 
children whom we have attended with hooping-cough, continue under 
our charge, and as only in a very few cases do any symptoms of em- 
physema persist, we must conclude either that it less frequently attends 
pertussis than would naturally be supposed, or else that the lung-tissue 
soon regains its elasticity, and the over-distension of the air-vesicles 
disappears. In some instances, and especially in those where chronic 
bronchitis foUovvs the attack of hooping-cough, all the symptoms of 
emphysema may gradually develop themselves. 

Vomiting is a very frequent incident in pertussis, but ought not to be 
regarded as a complication, unless dependent on some disease of the 
digestive organs, or symptomatic of cerebral disease. Where it occurs 
in simple cases, or in those complicated with bronchitis or pneumonia, 
it has always seemed to us to be advantageous. 

Tuberculosis and scrofula are not infrequently found to follow hoop- 
ing-cough, in cases where a marked predisposition to these conditions 
exists. The tuberculous affection is most apt to take the form of pul- 
monary or bronchial phthisis. These sequelae are frequently observed 
in hospitals, and among the ill-fed and feeble children of the poor, but 
are comparatively rare among the better classes of society. 

Diagnosis. — The diagnosis of pertussis is difficult only during the 
first stage of the complaint. It is impossible, indeed, to distinguish, 
during that stage, between it and simple mild laryngitis, or the mild 
catarrhal attacks which are so common in our climate. After it has 
once fairly entered upon the second stage, it is scarcely possible to con- 



268 



HOOPING-COUGH. 



found it with any other malady. MM. Eilliet and Barthez state, how- 
ever, that acute bronchitis with paroxysmal cough is not unfrequently 
mistaken for pertussis, and we recollect perfectly having made this 
mistake ourselves, in a little girl, five years of age. The cough as- 
sumed so exact!}" the features of pertussis, that after waiting a few days 
we announced, authoritatively, the presence of pertussis. Ordy three 
or four days after this we were forced to take it all back, for the whole 
thing had disappeared, bronchitis, pertussis, and all. The patient was 
entirely well. But the mistake need seldom be made, if it be recol- 
lected tiiat in acute bronchitis with paroxysmal cough, the invasion is 
sudden ; that there is violent fever, great d^^spnoea, and the physical 
signs of bronchitis; that the hoop is generally wanting, or feebly 
marked, and that the disease is violent and rapid in its course ; all of 
which circumstances are widely different from what occurs in per- 
tussis. 

The same authors assert that tuberculosis of the bronchial ganglions 
gives rise to a cough which may be mistaken for pertussis. The follow- 
ing table extracted from their work will show the differences between 
the two disorders: 



PERTUSSIS. 

Often epiclemic, attacking several chil- 
dren at once; transmissible by contagion. 

Three distinct stages, of which only the 
second is accompanied by kinks. 

Kinks attended with hooping, ropy ex- 
pectoration and vomiting. 

Pure respiration in the intervals be- 
tween the kinks. 

In the intervals between the kinks, res- 
piration and pulse natural, so long as the 
disease is simple. 

Voice natural. 

Course generally acute. 



TUBERCULOSIS OF THE BRONCHIAL 
GANGLIONS. 

Always sporadic ; non-contagious. 
'No distinct stages. 

Kinks generally very short, without 
hooping, ropy expectoration, or vomiting. 

Physical signs of tuberculosis of the 
ganglions; but, in certain cases, absence 
of these signs. 

Accessions of asthma in some cases, 
with the kinks; continuous febrile move- 
ment, with evening exacerbations, sweats, 
progressive emaciation, &c. 

Voice sometimes hoarse. 

Chronic course. 



Prognosis. — Pertussis is rarely a dangerous or fatal disease so long as 
it remains simple. Of the 208 cases observed by ourselves, 143 were 
simple, all of which recovered. Nevertheless even the simple disease 
does sometimes terminate fatall}', from the excessive violence of the 
paroxysms of coughing. 

The danger in hooping-cough, which is considerable, depends, there- 
fore, almost entirely on the complications which are so ape to occur, 
for which reason the physician should watch with the closest atten- 
tion, in order to prevent their occurrence, and that he may recognize 
and treat them in their earliest stages. The most dangerous complica- 
tion is convulsions, and after that bronchitis and pneumonia. So long 
as the child seems well and lively, and without fever or dyspnoea^ in 



PROGNOSIS — NATURE OF THE DISEASE. 269 

tlie intervals between the fits, there is nothing to be feared. But if, 
on the contrary, it becomes hmgiiid and irritable, with indisposition to 
take food, feverishness, and some increase of the rate of respiration, 
the practitioner should be upon his guard. A very early age and natural 
delicac}' of constitution, are unfavorable circumstances in the disease. 
Some form of complication occurred in 65 of the 208 cases observed by 
ourselves. Of the 6b, 12 died. 

Five of the 12 fatal cases ended with convulsions. Of these 5 cases, 
the convulsions were caused by bronchitis and collapse of the lung in 
4, the fatal result being the consequence, in fact, of the lung complica- 
tion. One of the cases was independent, apparently, of disease of the 
lung (though, as no post-mortem examination was made, this cannot 
be asserted positively), but seemed to be the result of the violent laryn- 
gismus, with contracture and general convulsions, such as will be de- 
scribed in the article on laryngismus stridulus. Two of the cases 
occurred in children of eight and nine months old, respectively, and 
proved fatal in twenty-four hours after the setting-in of the convul- 
sions. Two others occurred in children in their second year, and the 
fifth occurred in a boy between three and four years old, and caused 
death in seven hours. 

Of the remaining seven fatal cases, one was the result of collapse of 
the lungs, supervening suddenly upon a mild bronchitis, in a twin child 
between two and three months old. The second w^as caused by tuber- 
cular disease of the lungs, in a ciiild between three and four years old, 
and the remaining five by bronchitis, associated, to a greater or less 
extent, in all probability, with collapse of the lung. Of the last men- 
tioned five cases, one occurred in a child between five and six months 
old, and was rapid in its course; two occurred in children betAcen 
one and two years old, one being rapid and the other lingering in its 
course; one occurred in the third year of life, and was attended with 
severe diarrhoea from teething, as well as with bronchitis and collapse; 
and the fifth occurred in a child in its fourth year, and was slow and 
gradual in its course. To sum up, it may be stated that of the 12 fatal 
cases, 10 were the result of bronchitis and collapse, 1 of tuberculosis of 
the lungs, and 1 of laryngismus stridulus. 

JN'ature of the Disease. — There is no essential anatomical lesion in 
pertussis, except, perhaps, slight inflammation of the bronchial mucous 
membrane. In most of the cases, the membrane lining the larger and 
smaller air-tubes, and very rarely that of the trachea, is reddened and 
perceptibly thicker than natural, and the tubes contain a considerable 
quantity of frothy mucus, or a thick, viscid, and tenacious phlegm. 

As to the nature of the disease, it seems to us very clear that it 
ought to be regarded as comprising two elements of morbid action, 
one of which consists in slight inflammation of the respiratory mucous 
membrane, and the other of disordered action of the respiratory sys- 
tem of excito-motor nerves. It is neither a pure neurosis nor a pure in- 
flammation, but partakes of the characters of both, and much more of 
the former than of the latter. The authors of the Compendium de Mcde- 



270 HOOPING-COUGH. 

cine Pratique (t. ii, p. 526) regard it as a neurosis, on the following 
grounds : " 1. In the greater number of cases the respiratory apparatus 
presents no kind of alteration, or else the lesions are so multiplied or 
variable, that they are surely not the real origin of the disease. 2. 
The clearly remittent course of the symptoms, and the total absence 
of fever, unless some complication is present, are not observed in ordi- 
nary or even specific inflammations. 3. The cessation or sudden return 
of the paroxysms, under the influence of moral emotions or change of 
place, behmg to a disorder of innervation, and not to inflammation^ 
which commonly passes through certain stages before it is resolved. 
4. The complete return to health, the integrity of all the functions in 
slight cases, the resistance which it opposes to treatment, the useless- 
ness of antiphlogistics, and the success obtained from narcotics and 
antispasmodics, are all so many circumstances peculiar to hooping- 
cough and to many of the neuroses." 

It has, however, so many points of resemblance to the various con- 
stitutional diseases, as its undoubtedly contagious nature; the facts 
that it runs a definite course, and that one attack protects the system 
against a second; that it also probabl^^ depends upon a morbid state 
of the blood, due to the introduction of some specific poison which 
possesses the peculiar power of irritating the pneumogastrie nerves. 

Treatment of Simple Pertussis. — Hooping-cough, like all other 
diseases, varies greatly in its degree of severity. It is sometimes an 
affair of no consequence scarcely, the patient passing through its 
stages without sufl'ering, and without any injurious consequences what- 
ever to the general health. We have known a large family of children 
to pass through the disease without other treatment than attention to 
a prudent hygiene, and with no other medicine than a few doses of a 
mild cathartic, given to relieve some uncomfortable gastric symptoms. 
We have known one child in a family where the disease was prevail- 
ing at the time, to have the cough for only five weeks, and to hoop 
only on two or three occasions, and to lose neither appetite nor spirits 
for a moment. Such cases evidently need no interference, and a wise 
physician wnll, in such, order no drugs. His business will be simply to 
direct that the child be guarded against cold and against imprudences 
in diet. 

In other instances the disease assumes, from a very early period, or 
sometimes not until later, a character of a very different kind. With- 
out any complication whatever, the natural symptoms of the disease 
develop in great intensity. The spells of coughing are very frequent, 
very violent, and very long-continued. Instead of some twenty spells 
or less in twenty-four hours, as is the rule in mild and moderate cases, 
the patient will average two or more every hour, having fifty or sixty 
spells in the day. The laryngismus, instead of being slight, will be 
violent and distressing, so that in lieu of three, four, or five hoops in a 
paroxysm, there may be fourteen or fifteen, and these so shrill, acute, 
and prolonged, as greatly to exhaust the poor little j^atient. Or the 
laryngismus may be so intense as to close for a few seconds the glottis^ 



TREATMENT — BLOODLETTING. 271 

and arrest eDtirely tbe respiration, giving rise to the most painful attacks 
of straggling and suffocation possible to behold. Or the vomiting may 
be so frequent as seriously to interfere with the nutrition of the child, 
and thus cause threatening and even dangerous debility. In certain 
families, and in certain epidemic types of the disease, it assumes these 
severe features, and such cases must take the same rank in this dis- 
ease that grave cases of scarlet fever, measles, or variola, take in those 
affections. 

Cases of this latter kind imperatively demand treatment, and they 
are, we are happy to state, susceptible very generally of great and 
striking alleviation, by the use of proper means, — means, too, which in 
themselves are verj^ safe. 

At one time we were very much disposed, we confess, to avoid all 
interference so long as we saw no complication in the case, under the 
supposition that the disease in its simple form was always safe, and 
might be trusted to the efforts of nature. More enlarged experience 
has taught us, however, that the very violence of the disease, even in 
its simple form, was a source of danger; and that, moreover, such severe 
cases were much more liable than milder ones to complications, while 
a proper treatment, instituted so soon as the disease began to show 
these severe characters, has almost always, after a few days' persever- 
ance, brought about and maintained a most evident amelioration of the 
symptoms, thus keeping within due bounds a development which might 
otherwise have gone on to a disastrous termination. 

Bloodletting. — Depletion is very rarely necessary in simple pertussis. 
The only cases in which it can be called for are those occurring in san- 
guine children, where the laryngismus is so extreme and the paroxysms 
so violent as to lead to great engorgement of the right side of the heart, 
and even to endanger the brain by overdistension of the veins. Under 
these circumstances, we might resort to venesection merely for the 
mechanical relief afforded, as recommended under similar conditions in 
pneumonia. In such cases only then, a small bleeding, or the applica- 
tion of a few leeches to the temples or behind the ears, may be proper; 
but even these may generally be safely treated by reduced diet and by 
a few doses of saline cathartics, without a resort to the more powerful 
and more permanently exhausting means of depletion. As for the treat- 
ment of simple pertussis by repeated venesections, in the hope of curtail- 
ing its duration, or under the idea of their being rendered necessary by 
the violence of the malady, it seems to us forbidden by the present state 
of medical knowledge, which informs us that the greater number of the 
cases do not endanger life so long as they remain simple, however vio- 
lent they appear to be. Of the 143 simple cases treated by ourselves, 
depletion was not used in any^ and all recovered. 

Narcotics and Antispasmodics. — Of the various remedies of this class 
which have been more or less extensively employed, the most impor- 
tant are belladonna, opium, and hydrocyanic acid. Assafoetida and, of 
recent years, several of the bromide salts have also been much used 
with apparent success. 



272 HOOPING-COUGH. 

Belladonna is highly recommended by several German authors, by 
MM. Killiet and Barthez, who state that it is beyond contradiction the 
one most deserving of confidence, by Trousseau and Pidoux, and by 
numerous Eno-lish and American writers. MM. Trousseau and Pidoux 

o 

employ the following formula: 

R — Pulv. Belladonnse, ....... gr. iv. 

Extract. Opii Aquos., gr. iv. 

Extract. Valerianae, ^ss. 

M. et div. in pil no. xvi. 

S. One to four in the course of the day. 

If the child dislike the pilular form, they give it in syrup, according 
to the following formula: 

]^. — Extract. Belladonnse, . ...... gr. iv. 

Sja-up. Opii, 

Sjn-up. Flor. Aurantii, aa . . . . . . f^j. — M. 

Of this, from one to eight teaspoon fuls are to be given in twenty-four hours. 

We have ourselves used belladonna in a very large number of cases 
of hooping-cough, and with such unquestionable benefit, that we re- 
gard it as one of the most valuable remedies for this disease in our pos- 
session. 

We have certainly never seen it cut short the course of the disease, 
as it has been asserted to do, but we have almost invariably found it to 
moderate the laryngismus, shorten the paroxysms and diminish their 
number, and probably also shorten the duration of the attack. We 
have not, however, been in the habit of prescribing such large doses of 
belladonna as those quoted above (gr. \) ; but have usually given it in 
combination with alum, in the dose of ^^^^th of a grain of the extract, 
every four hours to a child of one year old. The formula which we 
employ will be found in oar remarks upon the use of alum. 

Belladonna has also been largely used, especially by Dr. Fuller, in 
combination with sulphate of zinc, and with excellent results. This 
latter author states that he has observed a remarkable tolerance of 
belladonna in children, so tiiat, beginning with quite large doses, the 
amount may be rapidly, though carefullj^, increased until the quantity 
taken exceeds out of all proportion the corresponding doses which will 
be tolerated by adults. Even when given, however, in the comparatively 
small doses of 2^4 th or j2^\\ of a grain, it is necessary to watch for any 
symptoms of the toxic action of the drug, so that its administration 
may be suspended or the amount diminished. 

Opium is confessedl}^ a very valuable remedy in the disease, not as a 
curative, but as a sedative and palliative. When the cough is frequent 
and fatiguing, especially if the patient have an irritable and nervous 
constitution, some 023iate preparation is of the utmost service in mod- 
erating the frequency and violence of the paroxysms, and in allaying 
irritabilitj^ and restlessness. It is best given in the evening, and in 
combination with ipecacuanha. 



TREATMENT — ANTISPASMODICS — EMETICS. 273 

Hydrocyanic acid has been employed by various observers, and is 
highl}' spoken of by some. Its poisonous properties, however, have 
deterred many, and amongst them ourselves, from resorting to it. In- 
asmuch as there are other and safer means for conducting the disease 
to a fiavorable termination, it seems to us useless to venture upon so 
potent a preparation as this. Dr. Atlee, of Lancaster, gave it in the 
following formula: 

R. — Acid. Hydrocyan., rr^j. 

Syrup. Simp., f^j.— M. 

A teaspoonful to be given morning and evening, and if no uneasiness, 
dizziuess, or sickness be produced within forty-eight hours, the dose to 
be repeated three times a day. This prescription is for a child six 
months old ; one drop of the acid being added for each year of the 
child's age beyond one year. He has never repeated the dose more 
than four times a day. (Condie's Dis. of Child., 2d ed., p. 337.) 

Since the discovery of the powerful antispasmodic properties of the 
various bromides, they have been much used in the treatment of this 
disease. The bromide of ammonium has been recommended, especially 
by Gibb and G-. Harley, as a pharyngeal and laryngeal anaesthetic, to 
diminish the spasm of these parts, while, at the same time, the alkali 
acts by rendering the secretion from the bronchial mucous membrane 
more free and readily expectorated. The bromide of potassium acts in 
the same way, and is productive, probably, of equally good results. 
We have, also, used assafoetida in a number of instances with decided 
benefit, both in relieving the general restlessness and in moderating the 
number and severity of the paroxysms. The doses in which we have 
given it are either two or three grains in pill, or a teaspoonful of the 
mistura assafcetidse, three or four times a day to a child of four years old. 

Emetics and Nauseants are amongst the most important remedies in 
the treatment of hooping-cough, since they exert a powerful influence 
upon the disease, and unless carried to excess, are not in themselves 
likely to be injurious. Some authors recommend the administration of 
an emetic every day or every other day^ while others give them accord- 
ing to the necessity of the case. Believing that frequently repeated 
emetic doses are unnecessarily severe, and productive of too much 
fatigue and exhaustion, we have preferred in the simple disease to give 
only small doses of ipecacuanha from time to time, so as to moderate 
the violence of the cough. Tartar emetic is never necessary, and ought 
to be avoided, on account of its disposition to irritate and inflame the 
gastro-intestinal mucous membrane, and because of its exhausting effects 
on the general econoni}-. The syrup of ipecacuanha is the preparation 
we have almost always used. From ten to twenty drops, given three 
times a day to a child three years old, w^U very generally moderate the 
severity of the paroxysms. 

Purgatives are necessary in the simple disease only when constipation 
is present. The mildest ought to be preferred, in order to avoid irrita- 

18 



274 HOOPING-COUGH. 

tion and exhaustion. Castor oil, magnesia, or syrup of rhubarb are 
the best. 

Particular Bemedies. — Of the different specific remedies that have been 
employed, none have attained and maintained so high a reputation in 
this city as the carbonate of potassa, which, in the form of the cochineal 
mixture, is constantly used both by physicians and as a domestic remedy. 
The beneficial effects of this drug are equally recognized abroad, as 
may be judged from the language of Memeyer, who, when speaking of 
its use in hooping-cough (op. cit., vol. i, p. 101), says, " Its effect in short- 
ening the fits of coughing is often surprising.^' The following formula 
is the one generally administered: 

R. — Potass. Carbonat, 9j. 

Coccii, 9^^- 

Sacch. Alb., . • ^j- 

Aquse Fontis, . f^iv. — M. 

Give a dessertspoonful three times a day to a child a year old. Believ- 
ing the carbonate of potash to be the active agent in the mixture, we 
have generally left out the cochineal and used the potash alone, dissolv- 
ing it in equal parts of syrup of gum and water. We have frequently 
employed this remedy, and believe that it, with alum and belladonna, 
are the most useful agents we have to keep down the violence of the 
disease. We have given it in the dose of a grain three or four times 
in the twenty-four hours, to children one and two years old, for several 
weeks at a time, without witnessing any injurious effects from it. 

Alum was first highly recommended as a remedy in pertussis by Dr. 
Golding Bird {Guy's Hospital Beports, April, 1845). He states that in 
the second or nervous period of the disease, when " all inflammatory 
symptoms have subsided, and when, with a cool skin and clean tongue, 
the little patient is harassed by a copious secretion from the bronchi, 
the attempt to get rid of which j)roduces the exhausting and charac- 
teristic cough, alum will be found to be of much value." He adds, that 
he " has not yet met with any other remedy which has acted so satis- 
factorily, or afforded such marked and rapid relief." From reading Dr. 
Bird's remarks on alum, and prompted by our knowledge of its admir- 
able qualities in the treatment of croup, we were formerly led to make 
trial of it in the disease under consideration, and we believe we may 
say that it has exerted a more decided influence in moderating the vio- 
lence of the disorder, than any that we have ever made use of. We 
have administered it in 139 cases, beginning in the course of the second 
stage. In nearly all it was beneficial, and in some the effects were strik- 
ingly useful, the improvement being more rapid than we had ever seen 
to result from other remedies, or to occur when the disease has been 
allowed to pursue its natural course. In a boy, between five and six 
years of age, who had been coughing violently for two weeks, the par- 
oxysms diminished so much in intensity and frequency, after he had 
taken the remedy two days, that he was not once disturbed at night 
(though before he had always been waked several times), and the spells 



TREATMENT — ALUM. 275 

which occurred during the day were much less severe. After continu- 
ing the remedj for ten days, the disease had subsided so much that its 
employment was suspended. Soon after, however, the paroxysms again 
became severe and troublesome. The alum was resumed, and with the 
same results as at first. In another family in which there were three 
children, all of whom had been taking syru^) of ipecacuanha and car- 
bonate of potash for some daj'S, without any good effects, the alum was 
given and acted as in the case first referred to. The nights were com- 
paratively quiet, and the spells occurring through the day very much 
moderated. We may repeat that, so fiir as our experience in the above 
139 cases goes, the effects of alum have been more decided and satis- 
factory than those of any other remedy. We have never known it to 
produce ill consequences, either at the time of its administration or sub- 
sequently, though we have given it to children from two months to seven 
years of age, and have continued its use from one to six weeks at a 
time. It, like all other remedies, sometimes fails, however, to do any 
good, and when we have found this to be the case, we have substituted 
belladonna or carbonate of potash, either alone or combined, and it is 
curious to observe how, in some instances, the latter remedies will suc- 
ceed where the other fails. Nothing but a trial will show which is the 
most proper in any individual case. Of late years we have usually 
given the alum and belladonna together, and have been much pleased 
with the results. If administered in large doses, alum produces vomit- 
ing. It does not constipate, but on the contrary, is apt to induce diar- 
rhoea, when continued for some time. Dr. Bird gives from two to six 
grains every four hours. His formula is as follows : 

R. — Aluminis, . . . . . . . . . gr. xxv. 

Ext. Conii, gr, xij. 

Syrup. Khoeados, f^ij. 

Aquae Anetlii, f^iij- — M. 

Give a medium-sized spoonful every three hours. 

To children under one year, we give from half a grain to a grain, 
three or four times a day; and to those over that age, two grains every 
four or six hours. The formula we have employed is the following: 

R. — Aluminis, . . . . . . . . . . ^ijss. 

Syrup. Zingib., Syrup. Acacise, Aquae Fontis, aa, . . f^j. — M. 

When this is prepared with good syrups, it tastes very much like lemon- 
ade, and is not at all unpleasant, so that children take it without diffi- 
culty. The dose is a teaspoonful three times a day, or every four or 
six hours. 

As above said, however, we now generally employ a combination of 
alum and belladonna, and have obtained better results from it than 
from any single remedy we have ever used. For a child one year old 
we use the following formula: 



276 HOOPING-COUGH. 

R. — Ext. Belladonnse, gr. j. 

Aluminis, ^ss. 

Syr. Zingib., Syr. Acacise, Aquae, aa, fjj. 

M. et ft. sol. 
Dose, a teaspooiiful four times in the twenty-four hours : in the morning, at noon, 
bedtime, and once in the night, if the cough be troublesome. 

Among other remedies which have been highly recommended, but 
which we have never found it necessary to resort to, may be mentioned 
the following: 

Sulphur is much used by some German authorities, who greatly com- 
mend its effects both at the beginning and throughout the course of 
the disease. It may be given in powder diffused in milk or syrup, or 
in emulsion, in doses of three grains, two or three times a day, to chil- 
dren from two to four years of age. 

Subcarbonate of Iron has been successfully employed by Dr. Steyman, 
and by Lombard, of G-eneva. 

Dilute Nitric Acid, first recommended by Arnoldi, of Montreal, has 
been highly praised, especially by Gibb. 

Conium has also been frequently used, both alone and as an ingredient 
in formulae containing some of the other remedies here mentioned, and 
appears to alleviate the violence of the paroxysms, though to a less 
marked degree, we believe, than belladonna. 

Inhalations. — It was noticed in France, some years ago, that children 
suffering with hooping-cough, who lived in the neighborhood of gas- 
works, were rapidly cured; and the plan has been recently tried with 
success, of sending patients wnth this disease to inhale the fumes aris- 
ing during the purification of gas, which contain ammonia, vapor of 
tar, and several volatile oils. Dr. BertoUes (^British Med. Jour., Nov. 5, 
1864) states that ^'the register of the gas-works at Ternes, shows that 
during the previous six months, 901 patients have been subjected to 
the vapor treatment, of whom 219 were cured and 122 relieved." M. 
Commerege (id. loc.) has also reported the effects observed in 142 chil- 
dren who were brought under the action of the gases in the gas-works 
at St. Maude; and believes that the treatment produces excellent 
results at all stages of the disorder. In general, tw^elve seances, each 
of w^hich should be of two hours' duration, are required for the cure. 
We have ourselves known of quite a number of instances among the 
children of the poorer classes in this city, where patients, suffering 
with hooping-cough, have been allow^ed to inhale the fumes from the 
gas-works, and have experienced positive benefit. 

Tonics. — In a number of cases that have come under our notice, the 
patient has grown pale and weak in the course of the disease, and this 
Without any local complication, but from the disturbance of the diges- 
tive system that often exists to a greater or less extent, from the great 
frequency of the vomiting, w^hich prevents them from taking a suffi- 
cient amount of nutriment, and from the exhausting effect of the vio- 
lent muscular exertion undergone during the paroxysms. In such 
instances, when there has been no fever, or merely a little evening 



TONICS — TOPICAL APPLICATIONS. 277 

febricnla, Tve have employed tonics with mucli advantage, and never to 
the injury of the patient. "We have general!}^ made use of Huxham's 
tincture of bark, either alone, in doses of from ten to twenty drops 
three times a day. or in connection with the syrup of the iodide of 
iron, or half a grain of the metallic iron (Pulv. Ferri). When the ap- 
petite has been very feeble, we have found that quinine, in the dose of 
a grain three or four times a day, at the age of three or four years, has 
restored it more rapidly than any other remedy we have used. 

Local Applications. — Bevidsives, — The milder revulsives are useful 
in certain complications of pertussis, and as palliatives. To make them 
the chief basis of the treatment, however, which has been done by some, 
is a mistake. In order to produce a decided impression upon the dis- 
ease, it would be necessar}- to resort to the more powerful remedies of 
this class, such as moxas, issues, tartar emetic ointment, blisters, &c., 
the use of which is not warranted by the nature of the disorder. 

When the laryngismus has been severe, we have known the use of a 
belladonna plaster, 2 by 3 inches, applied over the larynx and worn for 
several days, to afford relief 

Topical app/ications to the interior of the larynx of solutions of ni- 
trate of silver have been used by several practitioners, as by Gibb and 
Eben Watson, and apparently with much benefit. The strength of the 
solution should vary according to the stage of the disease, being much 
reduced during the early acute period. 

Before concluding our remarks upon the treatment of simple hooping- 
cough, we wish to state that cases of the disease occur not unfrequently 
of so mild a form, as to need absolutely no treatment other than the 
proper degree of attention to hygiene; and that others again, more 
numerous than those just mentioned, will be met with, in which the 
onl}" treatment necessary is the use, for a few days or weeks, of some 
mild expectorant and opiate at night to lessen the severity of the 
paroxysms, or of moderate doses of alum, belladonna, or carbonate of 
potash. 

In infants particularly it is proper to give as little medicine as pos- 
sible, allowing the disease to go on without interference so long as it 
progresses safely. In a good many mild cases, small doses of paregoric 
and syrup of ipecacuanha, constitute the only remedies we have found 
necessary in the cases of infants. When, however, the paroxj^sms be- 
come numerous and violent, exhausting the strength of the child and 
distressing its nervous system, we must make use of some remedy to 
allaj^ the severity of the attacks. We have found the alum and bella- 
donna formula recommended above safe and effectual. At the ae:e of 
two and three months, we have usually given from half a grain to a 
grain of the former, combined with -J^th grain of extract of belladonna, 
three times a day, taking care to suspend it for a day or two if it caused 
troublesome vomiting or purging, and then resuming it in diminished 
dose. Or we have made use of a quarter or half a grain of carbonate 
of potash, also combined with the twenty-fourth part of a grain of the 
extract of belladonna, three or four times a day. 



278 HOOPING-COUGH. 

Treatment of the Complications. — If any of the diseases which 
have been mentioned as apt to occur during the course of pertussis 
should arise, the treatment which is proper for them in their idiopathic 
form must be adopted without regard to the hooping-cough, with the 
following reservation : that care must be taken not to use means of too 
powerful and exhausting a nature, or such as have a tendency to irri- 
tate the organ with which they come in contact. For, it must be recol- 
lected, that after the complication is cured, the patient has still the origi- 
nal disease to go through with, and therefore requires all his strength; 
and, moreover, the various organs of the body are predisposed, by the 
very fact of the existence of the original malady, to assume diseased 
action, should any irritation in the shape of a violent remedy be applied 
to them. 

The cases of bronchitis which came under our observation were treated 
in the simplest manner. The children were put to bed, the diet care- 
fully regulated, the bowels gently opened with castor-oil or syrup of 
rhubarb, and small doses of syrup of ipecacuanha or antimonial wine, 
with sweet spirit of nitre, were administered every two hours. Mus- 
tard poultices were applied once or twice a day to the interscapular 
space, and mustard foot-baths used every night, or more frequently, if 
the dyspnoea were considerable. If the bronchial secretions were very 
profuse, and the cough troublesome, the decoction or syrup of seneka 
was given in connection with occasional doses of laudanum or paregoric. 

The treatment of collapse of the lung should be that which is recom- 
mended in the article on that subject, modified, of course, as may be 
rendered necessary, by the existence of the hooping-cough. A mild 
emetic, if the patient seem strong enough to bear one; counter-irri- 
tants, and especially sinapisms or mustard poultices applied to the 
chest, nutritious food, and mild stimulants, as brandy, wine-whey, tinc- 
ture of bark, quinine, or aromatic spirit of ammonia, must form the 
principal means of treatment. 

The complication of pneumonia should be treated somewhat differ- 
ently. At the present time we should advise the use either of the 
combination of sulphurated antimony and Dover's powder, or of one of 
the alkaline mixtures, recommended in the article on pneumonia, in 
conjunction with external applications and the use of the foot-bath; 
and should not resort to bleeding, whether local or general, unless the 
indications, elsewhere laid down as calling for depletion in pneumonia, 
should be present in a marked degree. 

When convulsions occur they must be treated according to the cause 
which produces them, and the constitution and present state of the 
child. If the patient be strong and sanguine, and not exhausted by 
previous sickness, the treatment should consist of depletion by leeches 
to the temples, or behind the ears; of cold applications to the head; 
the warm bath; cathartics or purgative enemata; and revulsives in 
the form of sinapisms, or of a small blister to the nucha. If, on the 
contrary, the patient is of delicate constitution, or exhausted by long 
illness, and especially when the convulsions are the result of extensive 



TREATMENT OF THE COMPLICATIONS. 279 

collapse of the lungs, occurring spontaneously or supervening upon 
bronchitis, we must be content to resort to warm baths, revulsives, 
antispasmodics, and anodynes, stimuli, and stimulating enemata. 

Of the 12 cases of convulsions that came under our notice, 5 proved 
fatal. Two of the fatal cases occurred in children who had long been 
laboring under bronchitis, probably associated with collapse, that had 
baffled all treatment. Death took place within twenty-four hours 
from the appearance of the convulsions, which were in fact the result 
of the diseased condition of the lungs. No treatment further than the 
warm bath and sinapisms, was resorted to. In the third case, the con- 
vulsions came on in the seventh week of the disease, in a child who 
had been laboring for a number of days under severe bronchitis; they 
ended fatally in seven hours. The treatment employed at the begin- 
ning of the fit was a warm bath, an enema, and mustard plasters. 
After a few hours, solution of morphia with fluid extract of valerian 
were given by enema, cold was applied to the head, and a blister to the 
nucha. In the fourth case, which occurred in a child in the second 
year of its life, they were caused by bronchitis and collapse, and proved 
fatal in two days. The treatment consisted in the use of warm baths, 
counter-irritants, alum, and small doses of brandy. The fifth case 
likewise occurred in the second year. This was one in which all the 
symptoms of laryngismus stridulus — prolonged laryngismus, contrac- 
ture, and general convulsions — were added to those of the primary 
disease. It was treated with belladonna, opium, assafoetida, and warm 
baths, but all to no effect. 

Of the favorable cases, one occurred in a boy five months of age, on 
the third day of a severe attack of bronchitis. The child was imme- 
diately placed in a warm bath, and large sinapisms applied over the 
front of the chest and upon the extremities, when the convulsions 
ceased. After this he was treated with half-grain doses of alum, re- 
peated every three or four hours, mustard foot-baths, and poultices, 
and small doses of wine of opium. On the sixth day of the attack, the 
third after the convulsive seizure, there having been no return of the 
convulsions, the bronchitis subsided with copious sweats and cold hands 
and feet, for which small quantities of brandy and water and wine- 
whey were used. The recovery was perfect. A second case occurred 
in a hearty boy nine months old, and seemed to depend on congestion 
of the brain, brought on by a severe fit of coughing. In this instance 
a venesection to a small amount was performed, the child was placed 
in a warm bath, and cold applied to the head. ~No return of the spasms 
took place, and the child recovered without difficulty. In another case 
the convulsion was caused by an attack of fever depending on denti- 
tion, and was treated by lancing the gums, by a warm foot-bath, and 
by the administration of a grain of calomel in a teaspoonful of castor- 
oil. In the fourth case the convulsions were caused by pneumonia, 
and were managed by treating the pneumonia, except that at the mo- 
ment of the attack a warm bath and a stimulating enema were made 
use of. In a fifth the convulsion, which was a short one, occurred at 



280 HOOPING-COUGH. 

the onset of an attack of bronchitis. No particular treatment beyond 
what was necessar}^ for that disease was required. In a sixth, in a 
boy nine months old, the convulsion occurred suddenly, was violent, 
and lasted fifteen minutes. The cause could not be ascertained. The 
only treatment used for the convulsion was a warm bath. There was 
no return. In a seventh case, in a bo}" nine months old, a slight con- 
vulsion occurred during one of the paroxysms in the fifth week. JSIo 
treatment was necessarj^, as the attack was very short, and there was 
no recurrence of the symptoms. 

Hygienic Treatment. — This part of the management of the disease 
is of the highest importance, for it is by careful attention to its details 
that the complications which constitute the chief danger of the malady 
are to be prevented. In a considerable number of cases of pertussis, 
nothing more need be done than to insist upon strict attention to hy- 
gienic rules. The chief indications are, to preserve the child from tak- 
ing cold, and to prevent indiscretions in diet. The clothing ought to 
be warm, and during the autumn, winter, and spring, flannel should 
always be placed next to the skin. The child ought to be kept in the 
house during damp weather at all seasons, and whenever, during the 
winter season, it is intensely cold. The diet should be nutritious, but 
of easy digestion. All heavy, rich food ought to be absolutely forbid- 
den during the continuance of the malady. 

Treatment of the Paroxysm. — It often happens that the parox- 
ysms are so violent that the child seems to be in imminent danger of 
suffocation or of convulsions. This is especially true of infants. In 
six cases that we have seen, in infants under six months old, the kinks 
lasted so long, and the spasm of the larj^nx was so unj'ielding, that the 
children struggled as though laboring under tetanus; the countenance 
was disturbed and anxious; the face and hands, at first flushed, became 
purple from deep congestion ; and on some occasions the breathing was 
suspended for several seconds, so that life seemed for the time in the 
greatest danger. The difliculty in these cases depends on the spas- 
modic closure of the glottis, which is sometimes, no doubt, completely 
shut. We have never known these alarming symptoms of asphyxia to 
occur when the hoop has been clear and distinct, for when that is 
present, the larynx cannot be very tightly closed. 

When the symptoms above described occur in a child several years 
of age, the patient should be raised and supported in the sitting pos- 
ture; when in an infant, the child ought to be held lightly in the arms, 
80 that it may take any position which instinct prompts it to. At the 
same time, cold water ought to be sprinkled from the fingers upon the 
face, the child should be gently fanned, or, if the weather be warm, 
taken to the open window; and if there be time, it is well to put the 
feet into mustard-water. It has been recommended on such occasions 
to apply compresses dipped into cold water to the sternum. We would 
propose the trial of a means which the late Dr. CD. Meigs found very 
successful in arresting tonic spasm of the respiratory muscles, in a case 
of larjaigismus stridulus. This is the sudden application of a piece of 



TKEATMENT OF THE PAROXYSM. 281 

ice vrrapj^ed in linen to the epigastrium. When the laryngeal spasm 
is very intense and obstinate, a belladonna plaster, as before recom- 
mended, or a small blister to the front of the neck, may be useful in 
controlling it. 

M. Bell speaks very highly of the results obtained by sprinkling a 
little ether on the clothes of the patient at the onset of the paroxysm; 
and Dr. Churchill (Diseases of Childhood, p. 223), who has tried ether 
in 12 or 14 cases, and chloroform in 6, regards it as a valuable addition 
to our remedies. He directs that about half a drachm of sulphuric 
ether should be spilled on the nurse's hand and held before the child's 
nose and mouth at the commencement of a fit of coughing. In only 
one or two cases no benefit accrued, w^hile in others great mitigation 
of the spasm, and in three or four almost complete relief followed when 
the ether was thus applied. We should certainly recommend a trial 
of this procedure, making use, however, from preference, exclusively 
of the sulphuric ether. 



GLASS 11. 

DISEASES OF THE CIECULATOEY OEGAISTS. 
ARTICLE I. 

CYANOSIS. 

Synonyms. — Definition. — This peculiar condition, icnown under the 
various names of Morbus Coeruleus, or the blue disease, and Cyanosis, 
may be defined as a permanent state of lividity or blueness of the skin, 
depending upon numerous malformations or derangements of the heart 
and great vessels. 

In a comparatively slight degree, this condition attends many of the 
chronic organic diseases of the circulatory organs; and is also tran- 
siently present in the course of some acute diseases; but under neither 
of these circumstances does the lividity merit consideration as a sepa- 
rate affection, being merely due to the imperfect oxygenation of the 
blood. 

There is, however, one form of cyanosis which we have occasionally 
met with that merits a special reference. In these cases, the blueness 
of surface has appeared from three or four days to as many weeks after 
birth, has been intense in its degree, and associated with marked dis- 
turbance of respiration, and yet, under proper treatment, the infants 
have usually recovered. We believe that the cause of such cyanosis 
is to be found in atelectasis of the lungs, which acts partly by causing 
general venous congestion, and partly perhaps by obstructing the flow 
of blood through the pulmonary artery, so that the right cavities of the 
heart become over-distended, and there results an admixture of venous 
and arterial blood through the still unclosed foramen ovale. 

Before attempting to explain the peculiar blue color in cases of true 
cyanosis, it will be convenient to allude to the various lesions which 
have been found present in such cases. 

Morbid Anatomy. — The blood in cyanosis is dark, and contains an 
excess of carbonic acid; it has also lost, to a great extent, its coagu- 
lability. The only organs beside those of circulation which present 
lesions, with any constancy, are the lungs. 

Dr. J. Lewis Smith (D/s. of Infancy and Childhood, 1869, pp. 578- 
599), who has studied this disease with great care, and collected all the 
cases of it upon record, finds the condition of the lungs recorded with 
more or less minuteness in 110 out of 191 cases. In 26 cases there was 



CYANOSIS — MORBID ANATOMY. 283 

tuberculosis, either confined to the lungs, or chiefly exhibited in these 
organs J in 35 cases the lungs were of small size, either from compres- 
sion by etfusion in the pleural sacs or pericardium, or sometimes, appar- 
ently, from the persistence of the foetal state over a greater or less 
portion of the organ. In 35 cases the lungs presented a dark color, 
owing either to atelectasis or to engorgement and congestion. In 9 
there was emphysema in a part of the lungs; in 2^ pneumonia; in 2, 
the color was pale; in 1, a bright crimson ; in 1, the lungs were larger 
than natural; in 1, the right lung was absent; and in 17, these organs 
were recorded as healthy. 

There is also found, in a large proportion of cases, venous conges- 
tion of the brain, liver, or kidneys. By far the most marked and im- 
portant lesions, however, are those of the heart and great vessels, 
which are, excepting in extremely rare instances, the essential seat of 
the disease. The number of these lesions already recorded is consider- 
able, as will be seen from the subjoined table borrowed from Smith, 
which shows their character and relative frequency. 

1. Pulmonary artery absent, rudimentary, impervious, or par- 

tially obstructed, 97 

2. Eight auriculo-ventricular orifice impervious or contracted, . 5 

3. Orifice of the pulmonary artery and the right auriculo-ventric- 

ular aperture impervious or contracted, ..... 6 

4. Right ventricle divided into two cavities by a supernumerary 

septum, . . . . . . . . . . .11 

5. One auricle and one ventricle, 12 

6. Two auricles and one ventricle, ....... 4 

7. A single auriculo-ventricular opening; interauricular and inter- 

ventricular septa incomplete, 1 

8. Mitral orifice closed or contracted, 3 

9. Aorta absent, rudimentary, impervious, or partially obstructed, 3 

10. Aortic and the left auriculo-ventricular orifices impervious or 

contracted, . . . . . . . . . .1 

11. Aorta and pulmonary artery transposed, 14 

12. The cavse entering the left auricle, ...... 1 

13. Pulmonary veins opening into the right auricle, or into the 

cavse or azygos veins, 2 

14. Aorta impervious or contracted above its point of union with 

the ductus arteriosus ; pulmonary artery wholly or in part 
supplying blood to the descending aorta through the ductus 
arteriosus, 2 

162 

It is evident from a glance at this table, that the vast majority of the 
above lesions must occur before the full development of the heart is 
attained; and that consequently, in nearly every instance, cyanosis is a 
congenital affection. Eut further than this it will be observed, that in 
the first four groups in Smith's table, or in 119 out of 162 cases, the 
lesions affect the right side of the heart, and are precisely of the kind 
that we know are caused by inflammation of the endocardium. Bear- 
ing in mind then the well-ascertained law, that endocarditis occurring 



284 CYANOSIS. 

during foetal life, almost exclusively attacks the right side of the heart, 
we can readily understand how such lesions could be produced by an 
attack of inflammation affecting either the valves of the pulmonary 
artery, or the tricuspid valves, or some part of the lining membrane of 
the right ventricle. Should such an attack of endocarditis occur after 
the development of the cavities and septa of the heart, and the closure 
of the foramen ovale and ductus arteriosus, and lead to occlusion of the 
orifice of the pulmonary artery, it would of course be impossible for 
life to be sustained. But where such a lesion is produced, while the 
interauricular and interventricular septa are still imperfect, and the 
ductus arteriosus patulous, so much compensation may be affected that 
life can often be prolonged for many years. Thus, it is evident, that 
the first effect of the closure of the orifice of the pulmonary artery, at 
such an early period, will be to cause a large portion of the blood from 
the right ventricle to pass directlj^ through the opening remaining in 
the interventricular septum into the left ventricle. Usually this opening 
is not free enough to relieve the right ventricle entirely, and there is 
consequently pressure exerted backwards on the blood entering from 
the right auricle, which forces part of it through the foramen ovale 
into the. left auricle, and thus still further relieves the fulness of the 
right cavities. As there is no outward current through the pulmonary 
artery, owing to the occlusion of its orifice, blood flows back into this 
vessel from the aorta through the patulous ductus arteriosus, and thus 
supplies the lungs. At the same time the bronchial arteries become 
much enlarged, and, in some rare cases, blood has been able to reach 
the lungs through abnormal branches from the internal mammary or 
intercostal arteries. In cases of cyanosis which prove fatal very soon 
after birth, the most diverse and inexplicable lesions, as before enumer- 
ated, may be found; but in those instances where life is prolonged, the 
heart is usually found to present the associated lesions above described: 
contraction or occlusion of the orifice of the pulmonary artery, imper- 
fect interventricular septum, and patulous foramen ovale and ductus 
arteriosus. In such cases, when the compensatory communications be- 
tween the right and left side of the circulation are free, life may be pro- 
longed for many years. 

This was very nearlj^ the condition found in the following case,^ the 
opportunity of examining and describing which we owe to the courtesy 
ofDr. G.H.Thomas. 

" The patient was a young man, aet. 22 years, who had been markedly cyanotic 
from infancy, and was poorly developed. He was unable to maintain a proper tem- 
perature. He sutfered constantly from slight dyspnoea, with occasional exacerbations. 
At the autopsy there was marked congestion of the abdominal viscera, and the gall- 
bladder was packed with gallstones. Both lungs contained numerous yellow miliary 
tubercles. 

" The heart was rounded. The cavities of the ventricles were not much enlarged, 
nor was there any hypertrophy of the walls of the left ventricle. The walls of the 

^ See Descriptive Catalogue of Path. Museum of Penna. Hosp., No. 1501, p. 84, by 
William Pepper, M.D. 1869. 



MORBID ANATOMY — ILLUSTRATIVE CASES. 285 

ri2:ht ventricle were, however, decidedly thickened, though not equalling those of 
the left. The septum ventriculorum was disproportionately thick, and terminated 
about one-third of an inch below the level of the origin of the aorta in a smooth, 
rounded edge, over which the endocardium was thickened. The septum also seemed 
inside of its normal position, so as almost to bisect the aortic orifice. The aorta, which 
was slightly dilated but quite healthy, thus communicated freely with both ventri- 
cles. The origin of the pulmonary artery was very much obstructed, owing to coa- 
lescence and contraction of its valves. The ductus arteriosus was, unfortunately, not 
preserved, but, owing to the large size of the pulmonary artery beyond the seat of 
obstruction, it had in all probability remained patulous. The foramen ovale was 
closed." 

In this instance, the orifice of the pnlmonaiy artery not being en- 
tirely closed, the opening in the interventricular septum had been large 
enough to allow the right ventricle to relieve itself in that way, and 
consequently the foramen ovale had closed. 

When writing of atelectasis pulmonum (p. 142) we called attention 
to the fact that in some cases, where the state of imperfect expansion 
persisted, the continued obstruction to the pulmonary circulation was 
followed by the same train of lesions, viz., patulous ductus arteriosus and 
foramen ovale, and dilated hypertrophy of the right side of the hearty as 
are consequent upon obstruction of the orifice of the pulmonary artery, 
and which, as in the latter case, might be attended with cyanosis. 

The mere persistence of the foramen ovale can scarcely be regarded 
as a cause of permanent cyanosis. It is quite possible that during the 
early days of extra-uterine life, a certain amount of cyanosis might 
exist owing to the admixture of venous and arterial blood allowed by 
this opening, but after the forces of the circulation become equalized, it 
is quite certain that the valve of the foramen may remain unattached, 
or may even be somewhat insufficient to close the opening, and yet no 
cyanosis be present. 

As an illustrative case of one of the rarer forms of cyanosis, and one 
which bears in the most interesting manner upon the theory of its pro- 
duction, we abstract the following from a more full account published 
in the Proceedings of the Pathological Society of Philadelphia} 

The child was a well-developed male, born at full term. No discoloration was 
noticed at birth, but on the twelfth day, as the grandmother was preparing to wash 
it, it had a convulsion, and from that time presented coldness of the extremities, 
gradually increasing lividity, feeble and rapid pulse, and moaning and sighing res- 
piration. 

During inspiration, the sternum and upper parts of the chest were elevated, but 
the lateral regions remained unexpanded, and there was marked recession of the base 
of the thorax. The percussion-resonance was diminished on both sides, but especially 
on the right. The vesicular murmur was puerile, except over the right side, where 
it was feeble. The cardiac sounds were decidedly louder at the right scapula than 
over the left. The cardiac impulse at the left nipple was very indistinct, and the 
sounds there feeble but natural. On pressing two fingers lightly to the left of the 
ensiform cartilage, close to the costal cartilages, a ver}^ distinct and quite vigorous 
impulse could be folt, one much more distinct than at the nipple. At this point, a 

1 Transposition of the Arteries. Dr. J. F. Meigs. Proc. of Path. Soc, vol. ii, p. 



286 . CYANOSIS. 

distinct blowing sound attended the systole of the heart. The diagnosis made at the 
time was : atelectasis of both lungs, of the right greater than of the left; dilatation 
with hypertrophy of the right ventricle ; obstruction of the pulmonary artery, and 
open foramen ovale. Death occurred on the forty-fourth day after birth. 

At the autops}', the body was very small and thin. The thorax was flattened later- 
ally, and contracted at the base. There was marked collapse of the lower lobes of 
both lungs, and especially of the right. The heart was one-half too large, and full, 
rounded, and distended with soft black clots. The walls of the right ventricle were 
very thick, and its cavitj^ quite small ; it presented the appearance we usually associate 
with the left ventricle. The walls of the left ventricle were thinner than those of the 
right ; and its cavity was much more capacious than that" of the right. The right 
auricle was dilated and considerably larger than the left. The foramen ovale pre- 
sented an opening at its lower aspect of about 2 or 3 lines in diameter. The orifices 
of the vense cavae appeared smaller than usual. 

The aorta and pulmonary artery were transposed. The aorta arose from the right 
ventricle in the usual position of the pulmonary artery ; the pulmonary artery arose 
from the left ventricle, and passing under the arch of the aorta, gave to the latter, 
just beyond the left subclavian, the ductus arteriosus, which was quite pervious and 
of considerable size. The valves of the heart were healthy and not transposed. The 
pulmonary artery was of the natural size ; and presented no obstruction at its point 
of origin. After giving oft" to the aorta the ductus arteriosus, it divided as usual into 
two pulmonary branches, which soon subdivided into others. 

The aorta was of full size and presented nothing unusual. It gave oflT at its arch 
the innominate artery, and then the left primitive carotid and the left subclavian. 
Just beyond the latter it received, from the pulmonary artery, the ductus arteriosus. 

The pericardium was normal in all respects. 

Theories as to the Production of Cyanosis. — In the vast majority of 
cases the malformation which causes cyanosis is of such a character as 
to allow admixture of the venous and arterial blood, and, at the same 
time, to interfere more or less with the circulation of this mixed fluid. 
Ever since the time of Morgagni, authors upon this subject have been 
divided in opinion as to whether the coloration of the skin were due 
exclusively to one or the other of these causes: obstruction to the car- 
diac circulation and consequent venous congestion, or intermingling of 
the venous and arterial blood. 

In regard to the first of these causes, although it has numbered among 
its advocates Morgagni, Louis, and Stille, it cannot be considered com- 
petent to fully explain all the cases and peculiarities of cyanosis, al- 
though such central obstruction will unquestionably aid in its produc- 
tion. 

Nor can the second theory be held exclusively suflScient, since not 
only are there cases met with where cyanosis is present and yet no ad- 
mixture of venous and arterial blood is possible, but also, on the other 
hand, where a considerable degree of admixture exists without the pro- 
duction of cyanosis. 

It seems necessary, therefore, as Smith has clearlj^ pointed out, that 
any theory which pretends to embrace all the elements of this complex 
condition, should embody a reference to the fact that the essential de- 
fect in cyanosis is a want of arterialization of the blood. 

Symptoms. — Even in cases where cyanosis is due to congenital or- 



SYMPTOMS. 287 

ganic lesions, the peculiar symptoms are not always present until some 
time after birtli. 

Thus, in 138 of the cases of cyanosis collected by Smith, the time at 
which lividity was first noticed is stated as follows : 

In 97 it was within the first week, and often within a few hours after birth. 

In 3 at 2 weeks. In 6 fmm 2 to 5 years. 

" 1 " 3 " a I a 5 u 10 " 

" 2 " 1 month. " 6 " 10 " 20 " 

" 7 from 1 to 2 months. " 1 " 20 " 40 " 

" 5 " 2 " 6 " " 1 over 40 years. 
" 5 " 6 " 12 " — 

" 8 " 1 " 2 years. 41 

Dr. Smith adds, "that in these 41 cases, in which blueness did not 
occur till after the age of one week, if the patient were less than two 
years old when it commenced, there was frequently no obvious exciting 
cause; but above this age, with three exceptions, such a cause is known 
to have been present. It is interesting to observe how trivial the ex- 
citing cause frequently is" (an acute attack of sickness, an attack of 
convulsions, difficult parturition, a fall, or even a severe blow), ^' and 
equally interesting to note how long patients have enjoyed good health, 
not having the least lividity, although the anatomical vice, to which 
the final development of cyanosis was due, had existed from birth." 

The most characteristic symptom of cyanosis is the lividity of the 
surface, which varies in different cases from mere duskiness to a deep 
purplish tint. This color also varies in degree in different parts of the 
body, being most marked in the distant and especially the dependent 
portions, upon the mucous membranes, and wherever the capillary ves- 
sels are abundant, as on the face. Its degree varies, finally, in the same 
case with the condition of the circulation. In slight cases, when the 
patient is quiet and the circulation tranquil, the discoloration of the 
surface may be imperceptible, but upon any exertion, and especially in 
the more severe cases, the lividity becomes much intensified. In some 
instances, such as that narrated by us below, there may be actual 
ecchymoses of the surface, as in purpura. 

The state of the general nutrition is much impaired, and the subjects 
of this disease are usually stunted and illy developed. In many in- 
stances the generative system appears even more imperfectly devel- 
oped than the rest of the economy. The temperature of the body is 
always reduced, and exposure to cold is very poorly borne. 

In a good many cases the thorax presents the deformity so often 
found in association with rickets, known as the "pigeon-breast." It 
usually happens, also, that the ends of the fingers and toes become bul- 
bous. Disturbances of the circulation and respiration are of frequent 
occurrence. Thus there is often some abnormal bruit heard in the car- 
diac region, due to the abnormal condition of the heart. The pulse 
may be regular and of fair volume, but more frequently is small, irregu- 



288 CYANOSIS. 

lar, or iDtermittent, and palpitation is very readily induced by exertion. 
The disturbance of respiration usually corresponds in degree with the 
embarrassment of the circulation. 

While the patient remains quiet his breathing may be easy and regu- 
lar, but usually any sudden movement or exertion or emotion is suflS- 
cient to induce a paroxysm of dyspnoea, during which the lividity of 
surface becomes much deeper. In infants these paroxysms not rarely 
terminate in convulsions. Headache is frequently complained of, and 
is very apt to be caused by whatever disorders the circulation. During 
the paroxysms of palpitation, pain is often complained of in the region 
of the heart, but is rarely persistent. 

Owing to the extreme venous stasis frequently present, there is a 
tendency to passive hemorrhages in cyanosis, which expresses itself by 
bleeding from the nose, mouth, stomach, or rectum, or under the skin. 
Oedema of the lower extremities is often met with as a temporary con- 
dition after long standing on the feet; it is also apt to appear and to 
invade the rest of the body towards the close of the case, when the cir- 
culation becomes more enfeebled. 

Modes of Death. — Many cyanotic patients die from the effect of 
some intercurrent acute disease, as hooping-cough or one of the exan- 
themata, all of which are very badly borne in this condition. 

The theory that venous congestion is opposed to the development of 
tuberculosis, was applied by Rokitansky to this affection; but without 
any suflScient ground, since, as we have seen alreadj^, tuberculosis was 
found as the cause of death in no less than 26 of the cases collected by 
Dr. Smith. 

In other cases death occurs suddenly, either during an attack of con- 
vulsions or a paroxysm of dyspnoea. 

In severe cases of cyanosis life is rarely prolonged more than a few 
years; but in less marked cases the patients may even attain middle 
age. In 186 cases collected by Dr. Smith, the age at death was as fol- 
lows : 

In 17 under age of 1 week. In 21 from 5 years to 10 years. 

" 10 from 1 week to 1 month. "41 " 10 " "20 " 

" 20 " 20 " " 40 " 
" 4 over 40 years. 

186 



So that in 67, or more than one-third, death occurred before the 
close of the first year; in 121, or more than three-fifths, before the age 
of 10 years; only 24 survived the age of 20 years, and 4 the age of 40 
years. 

We subjoin the histor}^ of a case of cyanosis which we had under ob- 
servation for several years, in which the symptoms of this peculiar con- 
dition were extremely well marked. 



" 12 




1 month to 3 months 


" 11 




3 months to 6 " 


u 17 




6 " " 12 " 


" 12 




1 year to 2 years. 


" 21 




2 years to 5 " 



TREATMENT. 289 

The above note was taken in December, 1869. Since our last edition, 
this case has terminated fatally, and a post-mortem examination proved 
the existence of marked congenital malformation of the heart, of the 
character already fully described, originating evidently in obstruction 
of the pulmonary orifice. 

J. "\V., jet. 16 years and 7 months, has been cyanotic since infancy, but for the past 
few years, at least, has enjoyed fair health. At present there is marked lividity of 
the lips and of the nose, especially at the extremity, which seems somewhat in- 
creased in size. His hands habitually appear as though stained with solution of car- 
mine, the skin being uniformly livid over the wliole hands, but becoming lighter 
colored on the forearms. Pressure partly removes the lividity, which returns slowly 
after the withdrawal of the pressure. At times there have been little ecchymoses of 
tbe surface, followed by tbe effusion of serum under the epidermis, and the formation 
of superficial excoriations, which have left small cicatrices. Only a few of these have 
appeared on the hands. 

These vascular disturbances are even more marked in the lower extremities. The 
feet are continually deeply livid ; and over their surface and the ankles, very numer- 
ous ecchymotic spots have appeared, which underwent the same changes as those on 
tbe hands, and have left shining cicatricial spots, of a deep blackish-red color from 
the deposit of pigment, and surrounded by a dark brownish stain. There has also 
been a good deal of oedema of the feet lately. All of these conditions have been im- 
proved by the use of tight-laced stockings. The skin of both the hands and' feet is 
rather soft and moist. The last phalanges, both of the fingers and toes, are mark- 
edly clavate and hypertrophied. Firm pressure upon them reduces their size ; but, 
upon withdrawal of the pressure, the blood slowly, returns, and they regain their 
former size. The temperature of the body is always low, and he suffers extremely 
from exposure to cold. 

He suffers somewhat from dyspnoea, even upon slight exertion, but less so than 
formerly. He is also troubled with cough during the winter months. There is 
marked deformity of the thorax, the first and second pieces of the sternum uniting at 
an obtuse angle, and the cartilages of the third, fourth, fifth, and sixth ribs, forming 
a marked prominence on either side of the sternum ; the ensiform cartilage is consid- 
erably def)ressed. 

The apex-beat of the heart is in the fifth costal interspace, and just inside of the 
vertical line of the nipple. The heart's action is regular, and at present there is no 
abnormal cardiac murmur, though two years ago there was a distinct soft systolic 
bruit. The pulse in the standing posture is 114, in the sitting, 108. He has occa- 
sional attacks of epistaxis, and suffers quite frequently from attacks of gastric dis- 
turbance attended with severe headache. 

Treatment. — In the form of cyanosis which we have described as 
depending on collapse of the lungs, the child should be placed in the 
position below recommended as rendering the heart's action most free; 
the temperature of the body should be carefully maintained, and a few 
doses of brand}" in water or breast-milk should be given at intervals. 
There is evidently but little good that can be done by mere medication 
in cj'anosis depending on malformations of the heart. When the heart's 
action is feeble and irregular, digitalis, iron, and quinia, maybe admin- 
istered. During the paroxysms of palpitation and dyspnoea, the best 
remedies are diffusible stimulants, such as Hoffman's anodyne, spirit of 
chloroform, ammonia, and brandy; and derivatives, such as sinapisms 
to the chest or hot mustard foot-baths. In cases where the digestion 
is markedly feeble, the use of vegetable tonics is indicated. 

19 



290 DISEASES OF THE HEART. 

By far the most important part of the treatment, however, is a strict 
attention to the h3'gienic conditions of the patient. He should, so fixr 
as maybe practicable, avoid all excitement and active exertion; his 
diet should be digestible and nutritious, his clothing should be warm, 
and, in addition, he should carefully avoid all exposure to severe cold. 

In cases where the venous congestion of the legs is marked and at- 
tended with oedema or with enlargement of the veins, laced stockings 
should be worn. 

It occasionally happens that cyanotic patients find that certain posi- 
tions afford them peculiar ease and comfort. Believing that in cases 
where the lividity appeared soon after birth (cyanosis neonatorum), it 
was due to a patulous condition of the foramen ovale, the late Dr. 
Charles D. Meigs was led to recommend {Diseases of Children, 1850, p. 
92), that such children should be placed upon a pillow, on the right 
side, the head and trunk being inclined upwards about 30° or 45°. 
The object of this position was "to bring the septum of the auricles 
into a horizontal position, so that the blood in the left auricle might 
press the valve of Botalli down upon the foramen ovale." 

In a certain number of cases the adoption of this recommendation 
has undoubtedly seemed to relieve the lividity, so that it is perhaps 
desirable that all cyanotic infants should be placed in this position; 
though from a glance at the anomalies in the formation of the heart 
which frequently attend cyanosis, it is evident that in most cases it 
could furnish no material relief. We are ourselves inclined to attribute 
the relief afforded by this position, not to any influence upon the fora- 
men ovale, but to the fact that the heart's action is far most free and 
unincumbered when the child is placed upon the right side, with the 
trunk somewhat elevated. 



AETICLE 11. 



DISEASES or THE HEART. 



As we are prevented, by the limits of this work, from giving any de- 
tailed account of many of the affections which merely occur in child- 
hood in common with adult life, we propose in this article to offer only 
a few practical remarks upon the differences presented by diseases of 
the heart occurring at these two periods of life. 

Apart from those congenital malformations of the heart, already dis- 
cussed in the preceding article, the diseases of this organ most frequently 
met with in childhood, are pericarditis, and acute and chronic endocar- 
ditis, with valvular disease. 

The most frequent causes of these affections are rheumatism, the pe- 
culiar alterations of the blood present in scarlatina, rubeola, and diph- 
theria, and extension of inflammation from the adjacent tissues, in cases I 



ACUTE PERICAKDITIS. 291 

of pleurisy or pneumonia. Of these well-recognized causes, rheuma- 
tism is by far the most frequent; for, although young children are com- 
paratively rarely the subjects of this disease, it is followed by some 
cardiac complication in a larger proportion of cases in childhood than 
in after years. This fact will be more fully referred to in our remarks 
upon rheumatism, where we dwell upon the importance of recognizing 
this marked tendency, and of watching most critically for the appear- 
ance of any symptom indicating that the heart has become involved. 
This extreme watchfulness is the more necessary, because it frequently 
happens in young children, that for several days before the development 
of any local articular trouble, there may exist marked rheumatic fever, 
with serious inflammation of the membranes of the heart. 

In a few instances an acute cardiac affection cannot be traced to any 
of the causes above-mentioned, but appears to occur idiopathically, 
without exposure to any recognizable exciting cause. 

So, too, in some cases of chronic valvular disease, and especially, it 
has seemed to us, of contraction and thickening of the mitral valve, the 
lesion cannot even be traced to any acute attack of endocarditis, but 
seems more akin to a fibroid degeneration, whose cause and early symp- 
toms have been obscure and entirely overlooked. 

Possibly, in some of these interesting cases, the real starting-point of 
the disease may have been an attack of endocarditis in foetal life, which 
partially spoiled the valve, and set on foot degenerative changes, which 
slowly increased until they produced fatal symptoms. 

Acute Pericarditis may occur at any period after birth. In very 
young infants it has been observed in conjunction with peritonitis, and 
was apparently due to erysipelas; while in other cases no cause could 
be assigned for its occurrence. The symptoms are, however, so vague 
and difficult to appreciate at this tender age, that the lesion is rarely 
recognized until after death. The infant is evidently in pain ; the fea- 
tures are pinched and shrunken, the skin hot at first, and the pulse and 
respiration greatly accelerated. The physical signs can, however, rarely 
be satisfactorily determined, partly because death usually occurs before 
the lesions reach any considerable degree of development. 

In older children the physical signs are often obscured by the coex- 
istence of some inflammatory condition of the lungs or pleura, and the 
existence of pericarditis can only be surmised by the presence of a de- 
gree of disturbance of the circulation and respiration out of all propor- 
tion to the amount of lung trouble. 

When, however, pericarditis occurs without any such complication, 
it may be often recognized by the seat of pain ; the existence of great 
dyspnoea, amounting at times to orthopnoea; the great frequency of the 
pulse, which is often small, and even irregular; the disturbance of cir- 
culation, as shown by lividity of the lips and face; and, finally, by aus- 
cultation and percussion, which reveal at first merely a friction-sound, 
and later, when effusion has occurred, distant and feeble heart-sounds, 
with an increased area of cardiac dulness. 

AYhen severe, pericarditis in children usually proves fatal. After 



292 DISEASES OF THE HEART. 

death the same anatomical lesions are found as after pericarditis in 
adult life. The membrane is, in the first stage, reddened, injected, drj'-- 
ish, and slightly roughened; while later it is still injected and even ec- 
chymosed, thickened, softened, and covered with patches or uniform 
layers of whitish or yellowish-white lymph, the surfaces of which are 
usually flocculent or irregularly roughened. The pericardial sac con- 
tains a variable quantity of turbid, or, at times, bloody serum; or, in 
secondary cases, a sero-purulent fluid. 

In cases w^here recovery takes place, the results of the previous in- 
flammation are found, after death has occurred from some other cause, 
in the form of more or less extensive adhesion of the two layers of the 
pericardium, or merely of thickening and opacity of that membrane. 

Treatment. — In idiopathic cases, if the disease be recognized in the 
earl}' stage, we should advise local depletion over the prsecordia by three 
or four leeches or cut-cups in a child of five years of age, followed by 
the application of warm mush-poultices, the depletion being repeated 
if indicated; the internal use of large doses of acetate of potash and 
iodide of potassium, associated with doses of veratrum viride of appro- 
priate strength, to quiet the excessive vascular excitement; and the 
careful administration of nutritious diet and small amounts of stimulus, 
if the powers of the circulation seem likely to yield to the influence of 
the disease. 

In the very rare instances where the disease becomes chronic, and 
the effusion remains unabsorbed, the treatment should consist in the re- 
peated application of small blisters over the prsecordia, and the internal 
use of iodide of potassium, iodide of iron, with tonics and nutritious 
diet. 

Endocarditis. — In many cases, acute endocarditis in children occurs 
in conjunction with pericarditis^ although it also occurs frequently as 
an independent affection. It is due to the same series of causes, also, 
as have been already enumerated when speaking of this latter disease; 
of these undoubtedly rheumatism is far the most frequent. And as it 
is of far more frequent occurrence than pericarditis, and productive of 
even more serious results, it is necessary that we should, if possible, be 
more upon the alert to detect the very earliest symptoms of its presence. 

In severe cases, whether occurring idiopathically, or as a complica- 
tion or sequel of some other disease, there is violent disturbance of the 
circulation, with great dyspnoea, and short, dry cough, without any of 
the physical signs of pulmonary disease. The child is extremely rest- 
less, and, upon auscultation, an abnormal bruit is heard attending the 
heart's action. 

In most cases, the mitral valve is chiefly affected in acute endocarditis, 
and the murmur detected on auscultation is heard over the body of the 
heart and to the left of this organ, and often has its seat of greatest 
intensity near the apex. We have most frequently observed the mur- 
mur to be S3^stolic in time, attending and more or less obscuring the 
first sound of the heart, in such acute cases. Of course, this indicates 
the existence of some imperfection in the closure of the mitral valves, 



CHRONIC VALVULAR DISEASES. 293 

allowing more or loss regurgitation of blood into the auricle with each 
contraction of the ventricle. Occasionally a double murmur, attending 
both the systole and diastole, and indicating roughness as M^ell as in- 
sufficiency of the mitral valve is heard. In more rare instances, we 
have found the aortic valves to be the seat of acute endocarditis, as 
shown b}' the presence of a single or double blowing murmur over the 
base of the heart, and transmitted most strongl}^ upwards over the upper 
part of the sternum to the second I'ight costal cartilage. 

But more frcquentl}^ the acute symptoms are not so marked or char- 
acteristic as this, and, when ensuing in the course of acute rheumatism, 
mav consist merely in a little increase of the heat of the skin, frequency 
of the pulse and restlessness, with or without vague complaints of pain 
about the prtecordia. 

Absolutely the only way of recognizing such cases is by auscultation, 
and consequently we would urge the immense importance of carefully 
ausculting the heart daily, not onh' in every case of acute rheumatism 
in a child, but also in every case where anomalous febrile symptoms, 
with acceleration of pulse, are present, and particularly if there be gen- 
eral soreness, or even resistance to motion. 

In very severe attacks of acute endocarditis, death may occur early; 
but more commonly the disease is less severe, and the urgent symptoms 
subside, leaving, however, in but too many cases, organic valvular dis- 
ease. 

When death occurs during the acute stage, the endocardium is found 
injected, reddened, softened, and readilj^ detached from the muscular 
wall. The lesions are most marked on the left side of the heart, and 
especially on the endocardium covering the mitral valve, where, in 
addition to the above-mentioned appearances, there are usually patches 
or rows of minute granular vegetations, which form a fine beaded line 
along the free border of the valves; or, in other cases, delicate fringe- 
like processes which hang from the leaflets. We have alluded at some 
length in our article on chorea, to the theory w^hich has been framed to 
explain the frequent occurrence of this latter disease in connection 
with rheumatism, by the separation of minute fragments of such vege- 
tations, and their impaction in some of the vessels of the brain. 

The treatment of acute endocarditis should be the same as that rec- 
ommended for acute pericarditis. 

CHRONIC VALVULAR DISEASES. 

There are certain general remarks which we desire to make in con- 
nection with these affections, which are applicable to them, without 
reference to the particular valve diseased : in addition to which, we 
will call attention to the diagnostic signs and special features of the 
diseases of each set of valves. 

Causes — Frequency. — In very many cases, heart disease in young 
children is recognized for the first time when such marked lesions exist 
as to convince us that the disease has already been of some consider- 



294 DISEASES OF THE HEART. 

able duration. Undoubtedly this is partly because the acute symptoms 
of the early stage have been entirely overlooked. This is particularly 
the case when the disease is rheumatic in its origin. We are convinced 
that acute rheumatism is often overlooked in young children, and also 
that endocarditis occurring in the course of such attacks not rarely 
escapes detection. It is, therefore, very difficult to say in what pro- 
portion of cases in young children, valvular diseases have been of acute 
origin. In our own experience they have, with the exception of con- 
traction of the mitral valve, almost universally followed an attack of 
endocarditis. In the case of mitral contraction, however, it is quite 
often impossible to trace the disease to any acute attack. It would 
appear, therefore, either that, contrary to the usual rule in early life, 
this lesion is often the result of a slow degenerative, fibroid change, or 
else that, in some cases, it may arise in foetal life. This latter view 
does not seem at all impossible when Ave remember how slow is the 
development of this lesion, and for how long a time it may remain 
latent. 

As to the relative frequency with which the different sets of valves 
are affected, lesions of the mitral valve undoubtedly preponderate 
largely. We have, it is true, met with extreme aortic disease in quite 
young children, marked by all the physical signs that are familiar as 
occurring in the adult; but such cases have been rare comj)ared to 
those in which the mitral valve was the seat of the disease. 

Anatomical Appearances. — The lesions which are found in chronic 
valvular diseases do not differ from those which are found in the adult, 
nor are they materially dependent upon the .mode of their origin. It is, 
however, probably true that in those cases which have followed acute 
endocarditis, it is more usual to find numerous and large vegetations 
upon the valves, than where the lesion has been chronic and of gradual 
development from the start. The lesions which are found usually, are 
vegetations or calcareous incrustations on the valves, or there may be 
thickening, contraction, and coalescence of the valves and their chordae 
tendinese, either of which conditions ma}^ be attended with contraction 
of the orifices of the heart, and obstruction to the passage of blood. 
On the other hand, the contraction of the valves may be in such a 
direction as to render them insufficient to close the orifice, and thus 
allow regurgitation. The effect of these lesions upon the walls and 
cavities of the heart will vary with their degree and suddenness of 
development. Usually they are followed by dilatation of the cavities 
involved, and by thickening or hypertrophy of their walls, which has 
usually seemed to us more constant and to bear a larger proj^ortion to 
the dilatation than in adults. 

Symptoms. — The general symptoms during the early stages of chronic 
valvular disease, are often extremely slight, consisting merely of some 
interference with the general development of the body; a little palpi- 
tation of the heart, and dyspnoea on exertion ; occasional prsecordial 
distress, and perhaps slight prominence of the cardiac region. 

The vague character of these symptoms accounts for the fact that, 



DISEASES OF THE AORTIC VALVES. 295 

after the subsidence of the acute symptoms of endocarditis, when the 
disease has begun in that way, such cases are very often neglected, and 
receive no proper care until the occurrence of dyspnoea, cough, and 
dropsy, gives warning only in time to recognize the approach of the 
fatal termination. 

We make these remarks especially to call attention to the insidious 
mode of approach of many cases of chronic valvular disease of the 
heart in children : and to impress upon our readers the important prac- 
tical rule that, whenever, in the investigation of a child suffering with 
obscure ill health, we learn of the previous occurrence of acute rheu- 
matism, or find mentioned among the symptoms any irregularities of 
the circulation or action of the heart, careful physical exploration of 
the heart should immediately be practised. 

The special symptoms which attend the diseases of the different 
valves, may be briefly described as follows: 

Diseases of the Aortic Valves. — These affections are, as already said, 
comparatively rare in children. The blowing murmur which attends 
them is usually strong and distinct. If the lesion causes obstruction 
of the aortic orifice, the murmur will attend the first sound; if there 
be regurgitation through the valve, it will attend or take the place of 
the second sound. In many cases the lesion causes both obstruction 
and insufficiency, and there is therefore a double murmur. In either 
case the murmur will be heard extending from the base of the heart 
upward and across the sternum to the second right costal cartilage, as 
well as downward along that bone to the xiphoid cartilage. It is also 
transmitted into the arteries. The murmur is often so loud that, espe- 
cially in cases of regurgitation, it may be heard down over the body of 
the heart to the apex ; and also to a varying distance on either side of 
the sternum over the upper part of the chest. Occasionally also a 
thrill may be felt over the upper piece of the sternum, in the second 
intercostal space at either the right or left edge of the sternum, or at 
the supra-sternal notch. 

The action of the heart is regular, and may not be accelerated, 
though exertion readily excites palpitation. The apex-beat is quick 
and strong, and is found after a time below and to the left of its normal 
position. The area of cardiac percussion-dulness also becomes moder- 
ately increased, in consequence of gradual hypertrophy of the walls of 
the left ventricle. 

The pulse is small, quick, and in cases of regurgitation, jerking and 
unsustained, or receding. 

In severe cases, there are marked evidences of interference with the 
arterial circulation. The surface is pale, and shows the insufficient 
amount of blood which passes through the arterial capillaries. 

The respiration is usually but little disturbed, excepting in conse- 
quence of unusual exertion, so long as the lesion is limited to the 
aortic valve, and the walls of the left ventricle undergo sufficient com- 
pensatory hypertrophy to overcome the obstruction to the circulation. 

The prognosis in aortic disease of moderate severity has not seemed 



296 DISEASES OF THE HEART. 

to IIS unfavorable so far as reojards prolono-ation of life. Thus, for ex- 
ample, we treated a girl of 9 J 3^ears, who had a violent attack of acute 
articular rheunriatism with endocarditis. This was followed by a double 
aortic murmur, which persists to the present time, although she has 
grown up, married, and has one child. Her health is delicate, and she 
has very moderate dyspnoea on exertion. We have frequently observed 
this same tolerance of serious aortic lesions for a number of years. We 
have never met with a case in which sudden death occurred in the 
course of aortic regurgitation, as so frequently happens in adults. 

Mitral Obstmction. — This interesting form of cardiac lesion would 
merit a more full description here than any other valvular disease, be- 
cause its symptoms are somewhat peculiar, and more es]3ecially because 
it is of such comparative frequency in childhood. 

Its origin, as we have already remarked, is usually insidious, and it 
is frequently impossible to gain any history of acute disease in cases 
where marked mitral obstruction is detected. 

The general symptoms which first attract attention to the heart are 
rarely noticed before the age of 7 or 10 years; and we may then learn 
that during previous years the child has seemed as active and playful 
as usual, or that he has always shown an indisposition to active play 
or exertion, and has become tired readily. Attention is attracted to 
the heart by the increasing tendency to dyspnoea and palpitation on 
exertion, and by the readiness with which cough of a bronchial char- 
acter is contracted on very slight exposure. Occasionally during these 
attacks of bronchitis with pulmonary congestion, haemoptysis may have 
occurred. Examination may now show the existence of prominence 
of the prfecordia; and the area of cardiac dulness is usually increased, 
though not to a marked extent. Frequentlj^ a thrill can be felt over 
the prsecordia, and careful examination will show it to occur just be- 
fore the apex-beat. We have known this thrill to begin distinctly 
about the base of the heart, and to extend quickly down towards the 
apex, terminating as the apex-beat was noticed. On auscultation, a 
murmur, usually of a low, hoarse, or churning character, is heard, 
which presents these additional pecularities : it is generally distinctly 
'presystolic or auriculo-systolic in time, occurring, that is, in the long 
period of silence preceding the first sound; its relation to the phe- 
nomena of the cardiac action can usually be determined without diifi- 
culty b}^ observing that it follows the second sound, and that it stops 
just before, or else runs into, the time of tiie first sound and the pulse 
of the carotid artery. This murmur, also, although usually quite 
strong, is, as a rule, reniarkably localized in comparison to other val- 
vular murmurs: its seat of greatest intensity is at or near the apex, 
and it loses force rapidly on leaving this point in any direction. At- 
tention to the peculiar physical signs above given, as well as to the 
general symptoms, will generally render the diagnosis clear. 

The prognosis, as regards prolongation of life and maintenance of 
comfort, is comparatively favorable; as regards improvement in the 
organic condition of the heart, it is of course entirely the reverse. We 



MITRAL REGURGITATION. 297 

have under oiir care at present a lad of 16 years of age who presents 
the typical symptoms of mitral obstruction, but who, by care in his 
manner of living, enjoys entire comfort. Usually, however, the fre- 
quent recurrence of pulmonary congestion injures more and more seri- 
ously the equilibrium of the heart's circulation and the efficiency of 
the right ventricle, and eventually grave symptoms of failure of cardiac 
power, with general venous stasis, appear, and increase until a fatal 
result occurs. 

Mitral Begurgitation. — This, which is the most frequent form of car- 
diac disease in young children, depends upon inflammatory alterations 
in the mitral valve, which render it insufficient to close that orifice 
during the systole of the left ventricle. In most cases it arises from 
an acute endocarditis, chiefly of rheumatic nature. In this condition, 
as in the last, the pulmonaiy circulation is apt to be disturbed from 
time to time, and therefore the early general symptoms which attract 
attention to the thoracic organs are usually shortness of breath on ex- 
ertion, liability to cough, and palpitation of the heart. Of course, 
where we are in attendance upon the case of rheumatism when the acute 
cardiac inflammation occurs, the fact will be recognized by the symp- 
toms detailed under the head of acute endocarditis. But unfortunately 
it often happens that this acute stage is quite overlooked, and w^e would 
therefoi'e again urge the importance of a careful physical examination 
of the heart in every case w^here a child is brought to us complaining 
of vague symptoms of embarrassed breathing, though no suspicion has 
ever been raised of the existence of heart disease. Sometimes, indeed, 
much more marked general symptoms will have appeared, as, for ex- 
ample, severe dyspnoea on exertion, pulmonary congestion with cough 
and moist or dry rales over the posterior parts of the lungs, palpita- 
tion of the heart, lividity of the lips and fingers, and even oedema of 
the feet. 

On 2:>hysical exploration we often find prominence of the prsecordia, 
with signs of more considerable hypertrophy and dilatation than in 
cases of mitral obstruction. The impulse is extended and too forcible, 
or may even be heaving; it is rarely attended with any thrill. On 
auscultation a blowing murmur, w^hich varies very greatly in different 
cases in its force and character, will be heard accompanying or replac- 
ing the first sound of the heart. This murmur is heard at the base, 
and is transmitted most strongly towards the apex, where it often 
has its point of greatest intensity. It is also strongly transmitted 
to the left of the apex, being w^ell heard in the infra-axillary space on 
the level of the apex-beat, and frequently, also, on the dorsum of the 
left chest, at the angle of the scapula. The only other form of valvular 
disease with w^hich it is possible to confound this is mitral obstruction; 
but attention to the evident j^oints of difference noted above will ren- 
der the diagnosis easy in most cases. 

The prognosis varies extremely in different cases, depending upon 
the extent and rapidity of development of the lesion; the completeness 
with which the disturbance of the circulation is compensated by the 



298 DISEASES OF THE HEART. 

hypertrophy and increased power of the walls of the left ventricle; and 
the vigor of the system and the preservation of the tone and nutri- 
tion of the muscular fibre of the heart. This form of heart disease 
illustrates more clearly than any other the more favorable prognosis 
which may be made in manj' cases of organic valvular disease in chil- 
dren, as compared with the same condition in adults. This depends 
partly upon the fact that when the lesion is not extensive, and when 
the patient is placed under favorable circumstances, the heart accom- 
modates itself in its growth to the defective state of the valves, and 
overcomes the impediment to the circulation by acquiring increased 
propulsive force. 

Isot only, however, are the valvular lesions in childhood thus partly 
compensated by hypertrophy of the walls of the heart, but there is 
also an undoubted tendeucj", in some favorable cases, for the valvular 
lesions, both mitral and aortic, themselves to diminish. Thus among 
the following cases, which we have selected from a large number of 
records collected in our practice, there will be found several where 
positive abnormal bruits, due to organic valvular disease, have gradu- 
ally^ disappeared in the course of years. 

Acute m^ticular rheumatism ; endocarditis; recovery; murviur persistent hut dirnin- 
ishing. — H. S., a boy, set. 12 years, had a severe attack of acute articular rheumatism 
in April, 1869, with swelling, redness, and pain of joints ; a systolic murmur appeared 
at the apex without any pericarditis. He recovered, under the use of alkalies and 
opium. In November, 1869, seven months after the attack, he seemed perfectly well ; 
had no dyspnoea except on violent exertion. The murmur at the apex is still audi- 
ble, but less marked than three months ago, when he was last examined. 

Acute endocarditis {rheumatic 9) ; marTied im^prove^nent in general sytnptom.s^ hut per- 
sistent murmur. — B. H,, a girl, at age of 4 years suffered from an ordinary catarrh, 
when we detected a loud, high-pitched murmur at the apex, and, on inquiry, learned 
that, when 2^ years old, she bad a violent inflammation of the chest, supposed to be 
catarrhal fever. At present, at the age of 12 years, she is in excellent health, with- 
out any of the rational signs of cardiac trouble, but she still has a well-marked, rather 
prolonged, high-pitched, systolic murmur at the apex. 

Repeated attacks of rheum,atism with severe mitral disease ; hnpirovement in general 
symptoms and force of the ■>nurmur. — L. S., a girl, was subject to attacks of rheuma- 
tism from very early age, and has presented symptoms of cardiac disease from in- 
fancj'-. At age of 13, there was a strong systolic murmur heard over base and toward 
apex. She suffered much from violent palpitation, pain in prsecordia, headache, and 
habitual dyspncea, much increased on exertion. At age of 18, there is still a sj'stolic 
mitral murmur, but of much less intensity than formerly. Her general health is ex- 
cellent, and she has but little dyspnoea or palpitation at any time. The heart's action 
is still readily excited; the impulse strong, but without thrill ; there is marked, in- 
crease in the area of cardiac dulness, but no positive prominence of the praecordia. 

Acute rheuynatic endocarditis^ chronic mitral disease ; recovery in five years. — F. R., 
a girl, at the age of 6 years, was attacked with slight rheumatic fever, without any 
articular symptoms. In a few days, a distinct but not loud, rather low-pitched sys- 
tolic murmur was heard at the apex. The treatment consisted of rest in bed, quinia, 
and Dover's powders. After ten days, all the acute symptoms disappeared, but the 
murmur continued. She regained her health, but for two years the murmur could 
be detected, but then graduall}' diminished; and now, five years after first attack, no 
murmur can be detected, the first sound at the apex being merely a little prolonged. 
Her general health is excellent. 



CASE. 299 

Acitte rhewnatic endocarditis ; valvular disease^ gradually recoverii^g in course of two 
years. — M B., a girl, at the age of 7 years had fever of a type that made us suspect 
pneumonia or pleurisy, but without cough, pain in the chest, or any of the physical 
signs of pulmonary disease. On the third day, there was complaint of pain in one 
groin, but with no other articular symptoms ; rheumatism being suspected, a careful 
examination detected a roughish systolic murmur at the apex. She was leeched at 
the prsecordia, confined strictly to bed, and had Dover's powders given her. The 
fever subsided, but the murmur continued for two years, gradually growing faint, 
and finally disappeared. 

It is however only when the general nutrition of the patient is good, 
so that the tonicity of the heart's tissue is preserved ; and when all ex- 
posure and exertion, which could overtax the energies of the crippled 
organ, are carefully avoided, that such compensation and gradual re- 
covery are possible. 

For in cases where the vigor of the heart's action fails, and degene- 
rative changes occur in its muscular tissue, the tonicity of the walls 
soon diminishes, and allows the develoj)ment of passive dilatation of 
the cavities. In this condition it is not long before the most grave 
symptoms of embarrassed circulation appear, and the case passes more 
or less rapidly through the stages common to fatal organic disease of 
the heart. 

The following case may be quoted as a full illustration of the latter 
remarks, in regard to the effect of exposure and exertion in inducing 
a fatal result in cases which otherwise might have gradually improved. 

Repeated attacks of acute rheumatism in early childhood; valvular disease and hy- 
pertrophy ; gradual improvement; exposure to hardships of army life; rapid aggra- 
vation of symptoms and death. — W. D., male, as a young child suffered from repeated 
attacks of acute articular rheumatism with cardiac complication. At the age of 9, 
Dr. Gerhard pronounced him to be suffering from valvular disease and hypertrophy 
of the heart. 

His condition was gradually improving, and he had so few symptoms of cardiac 
disease that, at the age of 18 years, he was able to enter the infantry service. At the 
end of one year, however, he was discharged for disability, and when seen by us in 
July, 1864, presented the following symptoms : bulging of prsecordia ; marked exten- 
sion of the cardiac impulse, which was heaving and powerful ; marked increase in 
the area of cardiac dulness from the presence of pericardial effusion ; and strong sys- 
tolic mitral murmur. He had lost flesh ; the surface was sallow and lips livid ; there 
was frequent cough with occasional htemoptysis and epistaxis ; the liver was enlarged, 
and there was frequently oedema of the feet. 

Towards the close of the year, the heart's action grew more labored and feeble, the 
pulse thready and frequent, the entire body became anasarcous, and considerable 
ascites appeared. He suffered from constant orthopncea and frequent cough, with 
bloody expectoration. The skin of the legs subsequently became gangrenous in parts, 
and he died December 28th. 

At the autops}^, the heart was found enormously enlarged, extending over to the 
right of the sternum. The pericardium was firmly adherent throughout its extent, 
and in places was ^ inch thick ; there were several cartilaginoid plates in the sub- 
stance of the investing pericardium. 

The heart measured 9^^ inches from apex to base, and 6 inches across at the base of 
the ventricles ; the walls of the left ventricle were 1^ inches thick ; the auricles were 
enormously dilated with very thin walls. The aortic and pulmonary valves were 
healthy and apparently suflScient ; the tricuspid valves were also health}', but proba- 
bly insufficient. The mitral valves had entirely disappeared, from shrivelling and 



300 DISEASES OF THE HEART. 

contraction, and there merely remained a very thick fibrous ring, studded with calca- 
reous masses, hounding the auriculo-ventrioular opening. 

The muscular tissue of the heart presented an incipient state of fatty degeneration. 

The liver was enormously enlarged, reaching nearly to the umbilicus, and presented 
intense nutmeg congestion. 

The kidneys were large and congested ; and the spleen was three times its normal 
size. 

Treatment. — Having spoken somewhat in detail of the symptoms 
and prognosis of the different forms of valvular disease in children, it 
remains to make some general remarks upon their treatment. In the 
management of such cases, as in adult life, the most important point to be 
attended to is the careful regulation of the mode of life. The child should 
be warmly clothed, and carefully protected from any exposure which 
might induce an attack of rheumatism; all violent exertion of body or 
mind should also be avoided, and, so far as possible, all sudden emo- 
tions, as fright or anger. On the other hand, care should be taken 
that proper gymnastic and outdoor exercise should be regularly taken 
in such ways as to invigorate the frame and strengthen the muscular 
system, without producing too much exhaustiors. The diet should be 
nutritious and digestible, and if the appetite should fail, and the child 
appear weakly and pale, vegetable tonics, with iron, should be admin- 
istered. 

The appearance of symptoms of pulmonary congestion, or of catarrh, 
should attract immediate attention, and lead us to employ counter-irri- 
tation and suitable expectorants to relieve the lungs. 

In cases where the heart's action is excited, and too frequent and 
powerful, while evidences of excessive hypertrophy begin to show 
themselves, we should employ cautiously veratrum viride or aconite to 
control it. When, on the other hand, any of the cavities of the heart 
are subjected to overstrain from valvular obstruction or insufficiency, 
and the heart is acting irregularly and inefficiently, the greatest benefit 
will be obtained from the use of digitalis. Indeed, in many instances 
we have observed, under the prolonged use of this drug, verj^ great per- 
manent improvement, gradually showing itself both in the action of 
the heart and in the general symptoms. 

Severe paroxysms of palpitation, should they occur, require the use 
of antispasmodics, diffusible stimuli, and revulsives, just as are indicated 
under the same circumstances in the adult. 

In cases of rheumatic origin especially, we have thought that good 
results, in regard to the progress of the organic changes in the heart, 
have followed the prolonged use of iodide and bromide of potassium, 
given with due regard to the danger of developing an anaemic state of the 
blood by the uninterrupted administration of these drugs for a long time. 

On the whole, as we have already said, there is reason to be some- 
what hopeful in the treatment of chronic valvular disease of moderate 
severity in young children, bearing in mind the wonderful power which 
the growing heart possesses of compensating such lesions, so long as by 
careful attention to hygiene and medical treatment we are able to pre- 
serve the tone and nutrition of its muscular tissue. 



CLASS III. 

DISEASES OF THE DIGESTIVE OEGANS. 
CHAPTER I. 

DISEASES OF THE MOUTH AND THEOAT. 

We find ourselves much embarrassed as to what classification of the 
diseases of the mouth is the most proper to adopt. So much confusion 
reigns amongst authors as to the nature of these affections, and conse- 
quently as to their nomenchiture, that it is very difficult to reconcile 
the various discrepancies which exist. After much consideration, how- 
ever, we believe that the followino; arrano-ement is the one best suited 
to the existing state of knowledge upon these affections: 

1. Simple or erythematous stomatitis. 

2. Follicular stomatitis, or aphthse. 

3. Ulcerative, or ulcero-membranous stomatitis. 

4. Gangrene of the mouth. 

5. Thrush, or stomatitis with curd-like exudation. 

6. Affections of the tonsils. 

7. Simple, or erythematous pharyngitis. 

8. Retro-pharyngeal abscess. 

In the previous editions of this work, we described pseudo-membran- 
ous pharyngitis in this place, but further observation and research have 
clearly established the fact that this is but the local manifestation of a 
constitutional affection, diphtheria; and we have accordingly given a 
full account of the whole subject, under this latter name, in the section 
on constitutional diseases. 



ARTICLE I. 

SIMPLE OR ERYTHEMATOUS STOMATITIS. 

Definition; Frequency.-— This form of stomatitis consists of simple 
diffuse inflammation of the mucous membrane of the mouth, unattended 
by vesicular or pustular productions, bj^ ulcerations, or by membranous 
exudation. It is a disease of infrequent occurrence, except in the form- 



802 APHTHA.. 

ing stage of other kinds of stomatitis, and of little importance, seldom 
requiring the attention of the physician. 

The causes of the disease are the introduction of irritating substances, 
such as hot drinks, and acrid or caustic preparations, into the mouth; 
difficult dentition; and probably sympathy with disordered states of 
the stomach. It occurs not unfrequently as a secondary affection, 
particularly in the course of measles, scarlet fever, and small-pox. 

The symptoms of erythematous stomatitis are more or less vivid red- 
ness of the mucous membrane, sometimes diffused, and at others punc- 
tated or disposed in patches; slight swelling of the same tissue; heat; 
and tenderness to the touch, and also in the act of sucking or eating. 
The child is generally fretful and restless, and either loses its appetite, 
or refuses to nurse or take food freely, on account of the tenderness of 
the mouth. There are seldom any general symptoms except in second- 
ary cases, in which they are those of the primary affection. 

The treatment is very simple. It consists in the use of some demul- 
cent wash, as gum-water, sassafras-pith mucilage, a little honey put on 
the tongue occasionally, and if the inflammation be at all considerable, 
in the application of some astringent preparation. This may consist 
of honey and borax, two or three parts of the former to one of the latter, 
or of the following wash, recommended by M. Bouchut: 

R.— Mel. EosEe, f^j. 

Aluminis, ...... ^ss. 

Aquae distillat, fjss. — M. 

The application of any of the washes recommended is best made by 
means of a thick and soft camel's-hair pencil; or it may be done with a 
soft rag, which should be dipped in the wash, and then conveyed into 
the mouth on the point of the finger. The remedy ought to be used 
several times a day. 

If signs of gastric or intestinal disorder are present, they should be 
attended to. 



ARTICLE II. 



APHTHA. 



Definition; Synonyms; Frequency; Forms. — The term aphthae 
0U2:ht to be restricted to the vesicular and ulcerous form of disease of 
the buccal mucous membrane, in which that tissue is covered with an 
eruption of vesicles which break, and are followed by small rounded 
ulcerations. Under this title writers formerly confounded the affection 
we are now considering with ulcerative stomatitis and thrush. It is 
called by Billard follicular stomatitis, and by several other writers vesic- 
ular stomatitis. 



DIAGNOSIS AND PROGNOSIS. 303 

The frequency of the disease is very considerable. We shall describe 
two forms, the discrete and confluent. 

Causes. — The only causes which seem to have been ascertained with 
any degree of certainty, are early age and the process of dentition : 
the contact of irritating substances, particularly stimulating and acrid 
articles of food, with the mucous membrane of the mouth ; and the 
existence of some morbid irritation of the digestive tube, especially of 
the stomach. The confluent form is often connected with severe gen- 
eral disease of the constitution. 

Symptoms ; Duration. — Aphth&e begin in the form of small red eleva- 
tions, having little white points upon their centres, which consist of 
the epithelium of the mucous membrane raised into vesicles. The 
vesicles are small in size, oval or roundish in shape, and of a white or 
pearl color. Thej' soon break and allow the fluid which thej^ contained 
to escape, after which there remains a little rounded ulcer^ with exca- 
vated and more or less thickened edges, and surrounded almost always 
by a red circle of inflammation. The bottom of the ulcers is usually 
of a grayish color. ^ There is seldom any diffuse inflammation of the 
mucous membrane in this disease. The number of aphthse varies in 
the two forms. In the discrete variety there are but few, whilst in 
the confluent form they are, of course, much more numerous. They 
generally appear first on the internal surfaces of the lips and gums, 
and then on the inside of the cheeks, edges of the tongue, and soft 
palate. 

The discrete form is generally accompanied by s^^mptoms of slight 
disorder of the digestive organs, consisting of thirst, acid eructations 
or vomiting, imperfect digestion, and a little constipation or diarrhoea. 
The confluent form, which is much more rare, especially in very young 
infants, usually coincides, as has already been stated, with severe gen- 
eral or local disease. 

The duration of aphthse is difi'erent in the two varieties of the aff'ec- 
tion. The discrete form generally pursues a rapid course, lasting from 
the beginning to the time of cicatrization, between four and seven 
days. Sometimes, however, when the vesicles are formed successively, 
one after the other, the disease lasts much longer. The confluent 
variety pursues a much slower course, and is much more difficult of 
cure. 

Diagnosis and Prognosis. — The diagnosis of discrete aphthge is not 
at all difficult, in consequence of their being isolated and succeeded by 
small and limited ulcerations. The confluent form, on the contrary, 
may be confounded with ulcerative or ulcero-membranous stomatitis, 
and with thrush. From the first-mentioned disease it may be distin- 

1 The grayish or yellowish-gray secretion, on the base of the aphthous ulcers, has 
lately been closely studied by Dr. J, Worms (Glasgow Med. Jour., July, 1864), who 
states that both microscopical examination and chemical tests invariably show its 
sebaceous nature. It is his opinion, therefore, that aphthae are the acne of the mu- 
cous membranes; in support of which, it will be remembered, that they are found 
most frequently where the muciparous glands are most abundant. 



304: APHTHA. 

guished, however, by attention to the circumstances that that affection 
begins by small white patches, and not by vesicles, as do aphthae; that 
the ulcerations which follow the patches are covered with true pseudo- 
membrane; and that the white patches just spoken of appear first 
upon the gums, whilst aphthae generally begin upon the posterior sur- 
face of the inferior lip, and upon the tongue. From thrush it is to be 
distinguished by the facts that that disease commences by w^hite points, 
which are not vesicular, and which, running together, form a creamy 
exudation; by the absence or very small number of ulcerations; and 
by the presence of the peculiar fungus of thrush. 

Discrete aphthae constitute a very mild disorder. They alwa^^s 
recover without much difficult}^. The confluent disease is more serious, 
because its progress is much slower, its cure more difficult, and because 
it is often connected, as has been stated, with some other severe disease. 

Treatment. — Aphthae, particularly the discrete variety, require in 
general, very simple treatment. The means to be emploj'ed are general 
and topical. 

The discrete variety usually requires only topical remedies, regulation 
of the diet, and when there are marked symptoms of gastric derange- 
ment, the exhibition of some mild emetic, or of a laxative dose. The 
local treatment should consist of applications of demulcent preparations, 
as the mucilages of slippery elm, sassafras pith, flaxseed, marsh-mallow 
root, quince-seed, &c., which are to be used- pure when there is no pain^ 
or with the addition of a few drops of laudanum or wine of opium, 
when the mouth is sore and tender; the aphthae ought to be touched 
occasionally with the mixture of borax and honey, or the aluminous 
preparation recommended for simple stomatitis. The applications 
must be made several times a day with a camel's-hair pencil, a pencil 
made of charpie or cotton, or with a soft rag covering the finger. 
When the ulcers which follow the vesicles fail to cicatrize rapidly under 
the above applications, or when they are numerous and painful, their 
cure may be very much hastened and the pain quickly relieved, by 
touching them lightly with a stick of nitrate of silver, or a piece of 
alum, sharpened to a point; or we may employ a pencil dipped into a 
strong solution of nitrate of silver, or into a mixture of one part of 
muriatic acid to two of honey. Ether has been highly recommended 
as a local application, by Dr. J. Worms, who, as already stated, has 
observed the fixtty nature of the deposit in aphthous ulcers. 

The general treatment of discrete aphthae need consist of nothing more 
than the prescription of a simple, unirritating diet in most of the cases. 
If, however, the digestive apparatus is deranged, the case must be 
treated according to the symptoms; by antacids or a gentle emetic, 
when the tongue is foul and the secretions acid; and by the use of a 
mild laxative, as castor oil, magnesia, or rhubarb, when there is con- 
stipation. When diarrhoea is present, we should resort first to a small 
dose of castor oil or syrup of rhubarb, with the addition of half a drop 
to two drops of laudanum, according to the age of the child, and after- 



TLCEKATIVE STOMATITIS. 305 

wards to astringents and opiates, as \Yill be recommended in the article 
on simple diarrhoea. 

The treatment of confluent aphthce must depend on their cause. The 
local treatment is the same as that for the discrete variet}^, except that 
cauterization should be resorted to at an earlier period. When they 
seem to depend upon a general morbid condition of the constitution, as 
cono;enital debility, a scorbutic diathesis, or upon chronic affections of 
the digestive organs, they must be treated in the first place by properly 
regulated and nutritious diet, and by the exhibition of tonics and gentle 
stimulants, particularly, iron, quinine, and small quantities of very fine 
old brandy; and in the second case, in the manner which will be rec- 
ommended for chronic derangements of the stomach and bowels, when 
we come to treat of the diseases of those organs. 



AETICLE III. 

ULCERATIVE OR ULCERO-MEMBRANOUS STOMATITIS. 

Definition; Synonyms; Frequency. — This form of sore mouth is 
characterized by a secretion' upon the mucous membrane of a plastic 
exudation in thick, yellowish, adherent patches, and by inflammation, 
erosion, or ulceration of the subjacent tissues. It is the same disease as 
the aphtha gangrenosa, and, we believe, the cancrum oris also of Under- 
wood ; the ulceration of the mouth of Dewees and Eberle; the stom- 
atite couenneuse, and the ulcerative and pseudo-membranous forms of 
the stomatite gangreneuse of M. Yalleix; the stomatite pseudo-membra- 
neuse or diphtheritiqae of some writers; and the stomatite ulcero-mem- 
braneuse of MM. Eilliet and Barthez. It is the disease described under 
the title of gangrenous sore mouth b}^ Dr. B. H. Coates {North American 
Surgical and Medical Journal^ vol. ii, 1826), with the exception of a few 
cases which were what we shall treat of as gangrene of the mouth. 

Of the different titles given above, we prefer that of ulcero-membra- 
nous stomatitis, as most expressive of the distinctive features of the dis- 
ease. This form of stomatitis is not very frequent in private practice, 
but sometimes prevails extensively in hospitals, and other public insti- 
tutions for children, where it often assumes an epidemic character. 

Causes. — The predisposing causes are epidemic influence, of the exist- 
ence of which we believe there is no doubt ; according to some observ- 
ers, contagion, which, however, has not as yet been positively shown ; 
and bad hygienic conditions as to cleanliness, ventilation, food, cloth- 
ing, and habitation. That it is epidemic, we have no doubt from our 
own experience, since we are rarely called to a case without soon meet- 
ing with others, while we sometimes pass several months without seeing 
a single example of the disease. We have also known it to be endemic in 
a household, having on one occasion met with seven cases in two families 

20 



306 ULCERATIVE STOMATITIS. 

of children residing under one roof, on two other occasions with three 
cases, and on several others with two. It is most frequent between the 
ages of five and ten years, though it may attack all ages, and is more 
common in boys than girls. It occurs during the convalescence from 
severe diseases, as pneumonia, the eruptive fevers, ty])hoid fever, entero- 
colitis, and other affections of children. 

The exciting causes of sporadic cases are unknown, with the excep- 
tion, perhaps, of the presence of a carious tooth in the mouth, and frac- 
ture or necrosis of the maxillary bones. 

Symptoms; Course ; Duration. — The disease begins with slight pain 
and uneasy sensations in the gums, which then become swelled, red, 
bleeding when touched, and are soon after covered with a grayish, pul- 
taceous exudation of varying thickness. The exudation extends from 
the gums to the internal surface of the lips and cheeks, and sometimes, 
but more rarely, to the soft palate, and even to the pharynx and nasal 
passages. The plastic dej^osit occurs in the form of small, and slightly 
projecting, yellowish patches, which approach each other, unite, and 
form bands of pseudo-membrane, somewhat uneven upon the surface, 
and adhering with considerable force to the tissue beneath. When the 
exudation is detached, the mucous membrane is found to be of a red or 
purple color, bleeding, and excoriated or ulcerated. The ulcerations 
which exist under the false membrane are of various depths, of a gray- 
ish, livid, or blackish color, with swelled, softened, and livid red, or 
bleeding edges. Those which are formed upon the inside of the lips 
are rounded in shape, whilst those seated in the angle between the lips 
and gums, are usually elongated. In mild cases of this affection, the 
local symptoms, though perfectly characteristic, are less severe than 
those just now described. The ulcerations are often few in number, 
amounting to four, five, or six upon the tongue, to a few scattered over 
the inner surfaces of the lips, and to some upon the gums, and espe- 
cially about the necks of the teeth. The other symptoms are the same 
as those above mentioned, with the exception that they are milder in 
degree. 

When the disease is mild, and when it is properly treated, the false 
membranes become detached, leaving the mucous tissue merely excori- 
ated, in which case it soon regains its natural condition; or else the 
ulcers which exist beneath rapidly become healthy and cicatrize. In 
violent cases and in those badly treated, the inflammation, on the con- 
trary, persists; the pseudo-membranes increase in thickness, or if de- 
tached, are formed anew; the ulcerations become deeper; the disease 
extends; and the case lasts an indefinite period of time. 

Other sj^mptoms, besides those we have mentioned, characterize the 
disease. 

The breath is always more or less fetid, and in bad cases, almost gan- 
grenous. The salivary and submaxillary glands are generally more or 
less swelled, hard, and painful, and according to some authors, the sur- 
rounding cellular tissue is in the same condition, though this is denied 
by others. The movements of the lower jaw are stiff and painful in 



DIAGNOSIS — TREATMENT. 307 

severe eases. Deglutition is not affected unless the disease extends to the 
pharynx. In violent cases there is usually a copious discharge of fetid, 
water}' saliva, or of bloody serum, which flows from the mouth during 
sleep. When the ulcerations are deep and large, the tissues beneath 
are more or less swelled; the swelling, however, rarely assumes the 
hard, resisting, circumscribed characters, with the tense, smooth, hot, 
and shining appearance of the skin, which exists in true gangrene of 
the mouth. In most of the cases there is a moderate but decided feb- 
rile reaction^ especiall}^ at the invasion. This usually subsides or disap- 
pears after two or three days, though it sometimes increases if the dis- 
ease becomes extensive. 

The disease begins, as already stated, on the gums, and unless limited 
to these parts, as sometimes happens, extends to the lips and cheeks. 
In many of the cases it attacks only one side of the mouth, and this is 
more frequently the left than the right. 

The course of the disease is usually rapid in epidemic cases, and in 
those which are properly treated. Where badl}^ treated, on the con- 
trary-, it may last from one to several months, or terminate in gangrene 
of the mouth. 

Diagnosis; Prognosis. — The diagnosis is, as a general rule, very easy, 
if proper attention be paid to the characteristic features of the disease. 
It has, as already stated, been very often confounded with gangrene of 
the mouth. The method of distinguishing between the two will be 
given in full in the article on that disease. From thrush it is to be dis- 
tinguished in the manner which will be pointed out when that disease 
comes under consideration. 

The prognosis is favorable in the great majority of the cases. Spo- 
radic cases probably always terminate favorably. The epidemic dis- 
ease, though rarely fatal, sometimes proves so from its extension to the 
pharynx and larynx, or from its termination in gangrene of the mouth. 
We have seen a large number of cases in private practice, and have 
never as yet known one to become gangrenous or to prove fatal. Of 
upwards of 120 cases of this kind, observed by Dr. Coates at the Phila- 
delphia Children's Asylum, in a period of three months, all but one 
recovered (Joe. cit., p. 21). The cases which occur in the course of 
other diseases are not dangerous in themselves, but are so as being the 
sign of a great severity of the primary affection. 

Treatment. — The treatment maybe divided into general, and local ov 
topical. The general treatment should consist in most of the cases in at- 
tention to the diet^ which ought, in healthy and vigorous children, to 
be simple and unirritating, and in those who are weak and debilitated, 
nutritious and digestible. If the bowels are costive, or the child fe- 
verish and uncomfortable, a laxative dose may be given with advan- 
tage; or some simple diaphoretic, as nitre and water, or the neutral 
mixture, may be used through the day, and a warm foot-bath or an 
immersion-bath given in the evening. When the constitution is feeble, 
and the child weak or anaemic, tonic remedies are indicated. The best 
is probably quinine, or one of the ferruginous preparations; or the com- 



T 

308 ULCERATIVE STOMATITIS. 

pound infusion of gentian, with addition of Huxham's tincture of bark, 
may be resorted to. The best internal remedy, however, and indeed 
the only one of any kind that is necessary in most cases, is the chlorate 
of potash, which possesses a stimulant and alterative action upon the 
mucous membranes. This is spoken of in the highest terms by Dr. 
West, of London, who regards it almost as a specific. We have used 
it now for many years past in a very large number of cases, and have 
seldom found it necessary to employ any other means, excepting some 
mild cathartic dose where the bowels have been constipated, and a 
wash of borax or alum in honey of roses, or borax in simple honey. 
The symptoms have begun to amend in every case in from three to 
four or five days, and recovery has taken place in about a week or a 
little more. The dose is from two to three grains every four hours 
for a child three years of age. and four and five grains for one of nine 
or ten years. Mr. Hutchinson (Med. Times and Gaz., 1856), who be- 
lieves also that this salt is almost a specific in this affection, recom- 
mends it in larger doses than the above, giving as much as five grains, 
thrice daily, to an infant of one year old. We have usually prescribed 
it in the dose of two grains four times a day, in a mixture of syrup 
of ginger and water, for children three or four years old. 

Prior to the discovery of the efficacy of the chlorate of potash in this 
affection, the local treatment constituted the only effectual and reliable 
means of removing it, and the most violent and painful applications 
were thought necessary and were made use of. Strong solutions of 
nitrate of silver, and pure or diluted muriatic acid, were frequently em- 
ployed in severe cases. Xow, however, these caustic substances may 
probably be entirely dispensed with, except in cases that show a ten- 
dency to assume the form of gangrene of the mouth. In ordinary 
cases the only local applications that need be used, and these are not 
essential when the child resists very much, are demulcent washes to 
keep the mouth clean, to be employed in the manner recommended in 
the article on aphthae, and some mild astringent wash. This may consist 
of borax and honey, or borax and sugar, in the proportion of two or three 
parts of the former to one of the latter, or, what is in my opinion pref- 
erable to either of these, of a drachm of borax rubbed up with an ounce 
of honey of roses. 

Should the disease resist the treatment by the chlorate of potash and 
the simple washes just now recommended, we may employ the follow- 
ing combination, proposed by Dr. Dewees, and of which he says that 
it "has so far never failed us." 

R. — Sulph. Cupri, gr. s. 

Pulv. Cinch. Opt., ..... ^ij. 

Pulv, G. Arab., ^j, 

Mel. Commun., f^ij. 

Aquse Font., f^iij- — M. et ft. sol. 

The ulcerations to be touched with the mixture twice a day, with 
the point of a camel's-hair pencil. Or, we may resort to the following 



GANGRENE OF THE MOUTH. 809 

one, recommended by Dr. Coates (loc. cit.), and of which he says, that 
he '-settled down, after various trials, in the employment of the fol- 
lowing: 

R.— Sulph. Cupri, gij. 

PliIv. Cinelion?e, ^ss. 

Aquae, f^iv.— M. 

To be applied twice a day, very carefully, to the full extent of the 
ulcerations and excoriations." 

MM. Eilliet and Barthez recommend very highly the plan pursued 
by M. Bouneau at the Children's Hospital. This is to cleanse the 
mouth first, and then to apply dry chloride of lime (calx chlorinata of 
the Pharmacopoeia) to the diseased surfaces. The application is made 
by means of a piece of rolled paper, or a stiff pencil, which is to be 
moistened and then dipped into the powder so that some may adhere, 
or with the finger. The surfaces are to be gently rubbed with the 
powder, and after a few moments' contact, washed clean with pure 
water. This is to be done twice a day, until the ulcerations assume 
a clean, healthy appearance, after w^hich the following mouth-wash 
is to be employed : 

R.— Mucil. G. Acac, f|j. 

Syrup. Cort. Aurant., f^ss. 

Calc. Chlorinat., Bj.— M. 

The chief danger from the disease depends on the circumstance that 
it sometimes terminates in gangrene of the mouth, to be presently de- 
scribed. Any disposition to such a termination should be carefully 
watched, and the proper preventive means, consisting of local stimu- 
lating or caustic applications, with the internal use of stimulants and 
tonics, be at once resorted to. 



ARTICLE ly. 



GANGRENE OF THE MOUTH. 



Definition; Synonyms; Frequency. — Gangrene of the mouth is an 
affection which occurs chiefly in children of debilitated constitution, 
and especially as a sequel of some of the eruptive fevers. It begins 
generally by ulceration of the mucous membrane of the cheek, which 
after a longer or shorter time, runs into gangrene, and extends rapidly 
to the gums; after a few days, if the disease be not arrested, the cen- 
tral tissues of the cheek become thickened and indurated, an eschar 



310 GANGRENE OF THE MOUTH. 

forms upon the integument, and spreads in depth and width, until at 
last the cheek may be perforated, the whole side of the face and jaws 
destroyed, the teeth loosened, and the maxillary bones exposed and 
necrosed. It is known by a great variety of names : gangrsenopsis, 
cancrum oris, gangrsena oris, canker of the mouth, gangrenous erosion 
of the cheeks of Underwood; necrosis infantilis, gangrenous stomatitis, 
&c. It is infrequent disease in the hospitals for children in Europe, and 
a not uncommon one in institutions of the same kind in this country. 
It sometimes prevails endemically in hospitals. It is a rare disease in 
private practice, and we have as yet met with but few cases, excepting 
in yjublic institutions. 

Predisposing Causes. — The disease is nearly, but not exclusively 
confined to the period of childhood. It is most common between the 
ages of three and six years; is very rare, but does sometimes occur in 
infants; and is of nearly equal frequency, probably, in the two sexes. 
Unfavorable /i?/^ie;u"c co?i6?<Yiows constitute a strong predisposing cause. 
Children living in hospitals or an}^ crowded institution ; those whose 
parents are poor or in want, and whose constitutions have been 
greatly deteriorated by long illness, by the tubercular diathesis, or by 
acute diseases, are particularly apt to be attacked. It almost always 
follows upon some previous acute or chronic disease, particularly mea- 
sles, or some other acute exanthem; pneumonia; entero-colitis ; hoop- 
ing-cough ; long-continued malarious fevers, &c. MM. Guersant and 
Blache say {Diet, de 31ed., t. 28, p. 601), " The existence of some an- 
terior disease is a necessary condition of gangrene of the mouth; we 
have never known it, nor has M. Baron, to occur as an idiopathic affec- 
tion." It has been affirmed by some persons to be contagious, but this 
is exceedingly doubtful. The fact of its occurring sometimes in an 
endemic form has already been referred to. It has been known also 
to prevail as an epidemic. 

The exciting causes can rarely be ascertained with any certainty. 
The only one which seems to have been proved to exist in some in- 
stances is the exhibition of large doses of the mercurial preparations, 
and even this is questioned by some very good authorities. 

Anatomical Lesions. — Upon examination after death, it is found 
that the integument surrounding the mortified spot soon runs into putre- 
faction. The lijD or cheek in which the disease is seated is swelled, 
hardened, tense, and shining, of a purple or greenish color, and pre- 
sents a deep, circumscribed engorgement. On the most prominent 
part of the swelling there often exists a rounded or oval, and distinctly 
limited eschar, of variable size, from a third of an inch to an inch, or 
even more, in diameter. In some instances the cutaneous slough is 
much larger, and extends irregularly to different parts of the face, to 
the chin, neck, eyelids, and even to the neighborhood of the ear, so as 
to occupy the whole of one side. Under these circumstances the tume- 
faction is neither so considerable, nor so regular, as when the slough is 
smaller. The eschar is always black, and generally dry and parchment- 
like, and extends a third or two-thirds of a line in depth^ or quite 



ANATOMICAL LESIONS. 311 

throno^h the integument. The tissues benefith the skin are not gener- 
ally implicated, though in some cases the eschar is detached and there 
is a perforation of the cheek through which may be seen the alveolar 
processes. 

Tlie mucous membrane of the mouth is alwaj'S affected with mortifi- 
cation. The disease may be limited, so as to exist in the form of an 
elongated ulceration, of a dark grayish color, situated in the fold where 
the mucous membrane is reflected from the cheek to the lower jaw; 
or. in a larger proportion of cases, it is seated on the internal surface 
of the cheek, opposite the interval between the alveolar processes. 
Sometimes the disease is much more extensive, and occupies all or a 
part of the internal surface of the cheek. In such instances the whole 
thickness of the mucous tissue is destroyed, and it presents uj^on its 
surfiice a blackish or brownish pultaceous slongh, almost liquid in con- 
sistence, which may be scraped off with a scalpel, leaving beneath loose 
shreds of mucous membrane, without any trace of organization. The 
gums frequently participate in the disease, and are converted into 
shreds, or completely destroyed. 

The maxillary hones are sometimes, in severe cases, when. the disease 
has extended to the gums, exposed, blackened, and even necrosed. The 
teeth are very often uncovered and loosened, and not unfrequently some 
are lost. The tissues between the skin and mucous membrane are found 
either hardened and infiltrated, or sphacelated to a greater or less ex- 
tent. In the least severe cases, the fatty cellular tissue and the mus- 
cular structure of the cheek are infiltrated with serum, but preserve 
their organization. When the disease is more aggravated, the gangrene 
extends to these tissues also, and always to those adjoining the mucous 
membi-ane first; so that the cellular structure beneath that membrane, 
and then the muscles, are infiltrated with a sanious fluid, and either in 
a state of sphacelus or tending thereto, whilst some of the adipose 
tissue beneath the skin is still merely infiltrated. In yet worse cases, 
the sloughs formed on the two surfaces of the cheek come into contact, 
and if their separation from the sound parts has taken place, a perfo- 
ration is the consequence. 

The condition of the bloodvessels in the midst of the diseased parts 
has been carefully examined by MM. Eilliet and Barthez. These au- 
thors state that when the tissues of the cheek are merely infiltrated, 
the vessels remain healthy, permeable, and their parietes are scarcely 
or very slightly thickened. When the vessels run along the edge of 
the slough, they are still permeable, but their walls are thickened, and 
begin to assume the appearances of the mortified tissues. Lastly, when 
they traverse the centre of the eschar, they can still be traced out, but 
their canals are found obliterated bj' coagula, in the whole extent of 
the mortified parts; or else the coagula occupy the vessels at their 
points of entrance into and exit from the slough, while between these 
points their walls are thickened, tend to assume the color and softness 
of the putrefied tissues, and their canals are filled with pultaceous gan- 
grenous matter. The writers quoted do not suppose that the obliter- 



312 GANGRENE OF THE MOUTH. 

ation of the vessels is the cause of the sphacelus, since that change 
occurs only after the death of the surrounding tissues has already taken 
place. 

The disease very rarely occurs on both sides of the mouth at once, 
though this does occasionally happen. 

The submaxillary glands are nearly always in their natural condition, 
but in rare instances are softened and engorged. 

Gangrene of the mouth never, or very rarely, indeed, exists without 
lesions of other organs. Of these the most frequent are acute pulmo- 
nary affections, and after them, acute or chronic diseases of the gastro- 
intestinal tube, and then malarious fevers, pleurisy, pneumothorax, peri- 
tonitis, and nephritis. 

Symptoms; Course; Duration. — The following account of the symp- 
toms of the disease is taken chiefly from the work of MM. Eilliet and 
Barthez. Gangrene of the mouth generally begins during the course 
or convalescence of some acute or chronic disease, by ulceration, aph- 
thae, or phlycten^e of the mucous membrane, and, in rare instances, by 
oedema of the substance of the cheek. At the same time the face is 
pale, and usually continues so throughout the disease; the nostrils and 
eyelids are often incrusted, and the latter infiltrated or sunken, and 
surrounded by bluish circles; the lips are swelled and covered with 
scabs, or dry. The breath of the child is fetid from the beginning, 
and, as the disease progresses, becomes gangrenous. There is but little 
fever at first, unless the case be accompanied by some acute disease; 
the pulse is commonly frequent and small in the beginning, rising 
^gradually from 80 or 90 to 100 or 120, and becoming insensible towards 
the end. In cases occurring in the course of other diseases, the pulse 
rises sometimes to 120 or 140, and is larger^ and fuller. The child is 
generally languid and quiet at first, or more rarely cross and peevish. 
The strength may be either lost entirely, merely diminished, or the pa- 
tient may retain a^sufficient amount of force to sit up and observe what 
is going on around, and even to leave the bed the day before death. 
Half the children observed by MM. Eilliet and Barthez, in whom this 
symptom was noted, sat up in bed until, within a few days of the fatal 
termination. In most cases but little complaint is made of pain in the 
mouth, though in some it is said to be severe. 

The ulceration already spoken of as forming the first symptom of 
the disease is generally of a grayish color, and resembles very closely 
that which exists in the ulcero-membranous form of stomatitis. It 
may be seated either on the gums, in the fold formed by the junction 
of the cheek or lip with the gum, or on the inside of the cheek, oppo- 
site the space between the alveolar processes. It may present a gan- 
grenous appearance from the first day, or not until after two or three 
daj's; or lastly, it may pass through the stages characteristic of ulcera- 
tive stomatitis, and terminate in the affection under consideration. Dr. 
B. H. Coates {loc, cit.) describes, under the title of gangrenous sore 
mouth of children, the ulcero-membranous form of stomatitis, and a 
few cases of gangrene, and states that three or four children out of 120 



SYMPTOMS. 313 

affected with ulcerated gums "suffered small spots of mortification, 
and one, by the delay arising from the tardy report of a nurse, suffered 
necrosis in a j)ortion of an alveolus/' 

The ulcerations just described assume the following appearances as 
the gangrenous nature of the malady develops itself. They become 
grayish, and then dark in color, bleed easily when touched, and are 
covered with pultaceous sloughs, exhaling a characteristic fetid odor. 
The gangrene extends to the neighboring parts, from the gum to the 
cheek, or from the cheek to the gum, and implicates at last the whole 
side of the mouth, or of the lower lip. At the same time the affected 
cheek or lip undergoes a circumscribed infiltration, which is at first 
rather soft, but becomes afterwards firmer, and forms at last a hard 
and rounded knot or tumor in the centre of the cheek, which is now 
tense, shining as though smeared with oil, and pale, or marbled with 
purple spots, while the slough on the inside is of a brownish color, more 
extended in size, and sometimes surrounded by a dark ring. The hard 
tumor of the cheek just described usually appears between the first 
and third days after the sphacelation of the mucous membrane, though 
in some instances not until a later period. It is formed, as stated in 
the account of the anatomical lesions, by engorgement of the cellular 
and adipose tissues. The child, at this stage, is still able to sit up in 
bed and take notice, or shows evident signs of weakness and depres- 
sion ) the face is swelled and destitute of expression on the affected 
side ; a bloody or dark-colored saliva runs from the mouth, which is 
partially open ; the appetite is not entirely lost in all cases, the patient 
still demanding and taking food; vomiting is rare, but diarrhoea is 
almost always present ; the thirst is generally intense; the skin is warm 
and feverish, natural, or too cool, and almost always dry, the differences 
depending probably more upon the concomitant disease than upon the 
mouth affection. The respiration is natural or altered according to the 
nature of the primary disease, which is, as already stated, in a large 
proportion of the cases, a pulmonary affection. The intelligence is 
generally undisturbed, though in some rare cases there is insomnia, de- 
lirium, or piercing cries. 

If the disease continues to progress, as it almost always does when it 
has reached the stage we are describing, there appears in many, but 
not all the cases (8 of the 21 observed by MM. Eilliet and Barthez), a 
slough or eschar upon the most prominent and discolored part of the 
swelling of the integument of the cheek or lower lip. This generally 
makes its appearance between the third and sixth days of the disease, 
but in other cases, as early as the second, or not before the twelfth, or 
even later. The skin, at the point where the eschar is about to form, 
becomes purple, and then black; sometimes a phlyctena makes its 
appearance, which is very soon converted into a small, dry, black slough. 
This, if not limited by a process of separation from the living tissues, 
becomes larger and larger by the extension of the sphacelation, until 
it may, as already stated, embrace the whole side of the face. In grave 
and fatal cases, the gangrene sometimes extends to all the tissues of 



314 GANGRENE OF THE MOUTH. 

the cheek, and meeting at last, the disease which had commenced on 
the inside of the mouth, occasions a perforation, through which may be 
seen the teeth, alveolar processes, and the whole interior of the buccal 
cavity. In such instances as these, several of which we have seen in 
the Pennsylvania and Philadelphia Hospitals, the appearance presented 
by the child is, as may well be imagined, of the most pitiable kind. 
Even under these circumstances, however, with the cheek perforated, 
the edges of the opening irregular and covered with shreds of dead 
tissue, the gums destroyed, the teeth loosened, and the maxillary bones 
exposed, blackened, and perhaps necrosed, with a dark and fetid sanies 
flowing from the mouth or perforation, and a putrefactive smell infect- 
ing the air around, the child may retain, in some instances, its strength, 
so as to sit up in bed, ask for food, and drink with avidity. In other 
cases, on the contrary, the patient, at this stage, is exhausted to the 
last degree, and refuses both food and drink. During the closing stage 
of the disease there is generally profuse diarrhoea, rapid emaciation, 
dry skin, small, rapid pulse, and at last death in a state of utter pros- 
tration. 

In favorable cases the recovery may take place in the early stage, be- 
fore the integument becomes involved, and while the gangrene is lim- 
ited to the mucous membrane, or at a later period, after the slough has 
separated. In the first instance the child generally recovers without 
deformity, though we saw one case in which necrosis of about an inch 
of the front of the inferior maxilla took place, without any loss of 
the soft parts. When the child recovers after the formation of the 
cutaneous slough, a very rare event, the gangrene ceases to extend, 
the eschar separates and is cast off, the edges of the opening assume 
the appearances of a healthy ulcer, and after a length of time approach 
each other and cicatrize, leaving generally a large, uneven, discolored 
scar, like that of a burn, which remains through life a horrid deformity. 

The duration of the disease varies according to its termination. When 
this is unfavorable, which happens in much the larger proportion of 
cases, death usually occurs about the end of the first, or in the course 
of the second week, though it has been known to occur at a later 
period. In favorable cases the duration is commonly longer, particu- 
larly if a cutaneous eschar has been produced, as the separation of the 
slough and cicatrization of the ulcer which remains require a tedious 
and slow process on the part of nature. 

Complicatiojis are very apt to arise in the course of the disease. The 
most frequent is pneumonia. MM. G-uersant and Blache state that it 
exists in nine-tenths of the cases; MM. Eilliet and Barthez found it in 
19 out of 21; of the 19, it began in 8 during the progress of the gan- 
grene, and ajDparently under the influence of the latter, whilst in the 
remaining cases it existed before, and acted perhaps as a predisposing 
cause to the aff'ection of the mouth. Another and more dan^rerous com- 
plication is the occurrence of gangrene in other parts of the body, par- 
ticularly the soft palate, pharj-nx, oesophagus, anus, and more frequently 
the vulva and lungs. 



DIAGNOSIS. 



315 



Diagnosis. — Some authors have described as identical affections, 
under the title of gangrenous stomatitis, the disease under considera- 
tion and the one already treated of as ulcero-membranous stomatitis. 
This has been done particularly by M. Taupin, who is followed in his 
description by M. Yalleix {Guide du Med. Frat., t. iv). It seems clear 
to us, moreover, that Dr. B. H. Coates, in his very valuable paper on 
the '-gangrenous sore mouth of children" (loc. cit.), mingles in his de- 
scription the two diseases referred to. We cannot bat think, however, 
that the differences between them as to frequency, sj^mptoms, course, 
amenability to treatment, and termination, which are fii 11}^ pointed out 
in the diagnostic table below, and lastlj^ the example of almost all au- 
thors upon this subject, fully warrant us in regarding them as different 
and distinct diseases. 

The diagnosis of gangrene of the mouth is, in most cases, very easy. 
The ulceration of the mucous membrane, followed by gangrene; the 
deepseated induration of the cheek, at first pale on the outside, then 
dark-colored, and terminating after a time in a characteristic slough; 
the course of the malady, and the nature of the general symptoms, will 
generally prevent any difficulty in the recognition of the disease. 

From stomatitis it may be distinguished by attention to the points 
laid down in the following table, taken from MM. Eilliet and Barthcz: 



STOMATITIS. 

Begins by ulceration or by pseudo-mem- 
branous plastic deposit. 

Odor very fetid and sometimes gangre- 
nous. 

But little extension of the local lesion, 
which always retains the same appear- 
ances. 

But little swelling of the cheek or lips, 
or simply cedema of those parts, without 
deepseated induration, tension, or unc- 
tuous appearance. 

Salivation rarely so considerable as to 
flow from the mouth ; when present some- 
times sanguinolont; never mixed with 
shreds of gangrenous tissue. 

Never an eschar on the exterior. 

Never complete perforation of the soft 
parts ; denudation of the bones never oc- 
curs ; loss of the teeth very rare. 

Course of the disease slow when left to 
itself; recovery rapid under the influence 
of treatment. 



GAN-QRENE. 

Begins by ulceration, which is some- 
times gangrenous from the first, or by 
oedema of the cheek. 

Odor always gangrenous. 

Considerable and rapid extension ; the 
tissues assume a peculiar dark grayish 
tint. 

Extensive swelling and oedema of the 
cheek, with deepseated induration, ten- 
sion, unctuous appearance, purple spots. 

Salivation abundant; constant escape 
of fluid, at first sanguinolent, afterwards 
putrefactive. 

Often an eschar upon the cheek or lips. 

Perforation of the soft parts frequent ; 
denudation of the bones constant ; loosen- 
ing of the teeth constant, and their loss 
frequent. 

Course rapid, and termination fatal, as 
a rule, when the disease is left to itself, 
and in spite of all treatment. 



Gangrene of the mouth may be confounded with malignant pustule. 
The method of diagnosis has been drawn by M. Baron in the following 
words: "Malignant pustule always begins on the exterior; affects the 



316 GANGRENE OF THE MOUTH. 

epidermis first, and extends successively to the corpus mucosum, chorion, 
and subjacent parts; whilst on the contrary, the gangrene under con- 
sideration attacks the mucous membrane first, then the muscles, and 
lastly the skin." 

Prognosis. — The prognosis of true gangrene of the mouth is exceed- 
ingly unfavorable. The great majority of the subjects die in spite of 
all that can be done. Dr. Coates {loc. cit., p. 14) says that a black 
spot on the outer surface of the swelling "has always been in my 
own experience the immediate harbinger of death. It is proper to 
state, how^ever, that I have heard it said that cases had recovered in 
this city, in which the gangrene had produced a hole through the 
cheek." MM. Eilliet and Barthez state that "death is the ordinary 
termination of gangrene of the mouth; though there are instances of 
recovery on record." Of 29 cases analyzed by them, only 3 recovered. 
MM. Guersant and Blache {loc. cit., p. 596) state that unless arrested in 
the formative stage, it ends fatally almost constantly in from five to 
ten days, and frequently before perforation has taken place. Of 36 
cases observed by M. Taupin in the Children's Hospital at Paris, not 
one escaped (Guersant and Blache, loc, cit., p. 597). The authors of 
the Compendium de Medecine Pratique say of this disease (t. i, p. 632), 
"Death is the almost inevitable termination." Dr. Marshall Hall {^Edin. 
Med. and Surg. Journ., xiv, p. 547) reports six cases of the disease, two 
of which followed measles, one repeated attacks of pneumonia, one 
fever (type not mentioned), one worm fever, and one typhus fever. 
All but one, the case occurring in the course of typhus fever, in a girl 
twelve years old, died. This girl recovered, with, however, falling in 
of the right cheek, "a frightful chasm" on the left side of the mouth, 
and caries of a portion of the alveolar j^rocess, palate bone, and second 
molar tooth. Recoveries sometimes occur, however, as in the case men- 
tioned by Dr. Hall, after perforation, but nearly always with terrible 
deformities, with adhesions of the walls of the mouth to the jaws, with 
incurable fistulse, &c. 

The prognosis is more favorable in private practice than in hospitals. 
The favorable circumstances in any case are: good hygienic conditions; 
vigorous constitution of the child ; the absence of dangerous concomitant 
disease; the continuance of appetite and strength; and a disposition to 
limitation and separation of the slough. Unfavorable symptoms are: 
weak and debilitated constitution of the patient; severe coexistent dis- 
ease; prostration of the strength; and extension of the sloughing pro- 
cess. Death may also occur from hemorrhage in consequence of the 
separation of the slough, as in a case quoted from Hueter by Bouchut. 

Treatment. — The reader need but refer to the remarks on prognosis 
to be assured that no treatment as yet discovered promises much suc- 
cess. We would call attention also to the following statement, — that 
the remarks about to be made apply only to true gangrene of the 
mouth, and not to all the cases described by some writers under the 
title of gangrenous sore mouth or even that of gangrene of the mouth, 



TREATMENT — LOCAL APPLICATIONS. 317 

since, as already stated, they confound together true gangrene and 
nlcero-membranous stomatitis. 

The treatment is divided into local and general. The local treatment 
recommended by the French writers, consists in cauterization of the 
sloughing parts with one of the mineral acids, with nitrate of silver, or 
with the actual cautery. This is the plan proposed by MM. Billard, 
Baron, Guersant and Blache, Barrier, Eilliet and Barthez, Bouchut, 
and Yalleix. The authors of the Bibliotheque de Medecin Practicien 
remark, however, that nearly all the patients subjected to cauteriza- 
tion die, and that of the small number saved, there are as many who 
had not been subjected to that treatment, as there are of those to 
whom it had been fully applied. They wonder, therefore, that recent 
authors continue to repose the same confidence in it, as did their pre- 
decessors. "For us," they sa}^, "we are of opinion that cauterization 
exerts but slight influence, if it have any at all, and it is greatly to be 
desired that the zeal of practitioners might discover some more effica- 
cious remedy" (loc. cit., t. v, p. 551). 

It is very important to make use of the caustic application as early 
after the beginning of the sphacelus as possible, for if it be allowed to 
spread to any considerable depth or extent, there is scarcely a hope of 
arresting it by any means. MM. Guersant and Blache recommend 
pure nitric, sulphuric, or muriatic acid ; MM. Eilliet and Barthez pro- 
pose the acid nitrate of mercury, or muriatic, sulphuric, or acetic acid; 
M. Yalleix proposes the treatment employed by M. Taupin, which is to 
remove the pseudo-membrane and a part or the whole of the gangren- 
ous eschar with scissors, to make some scarifications upon the healthy 
parts, to apply pure muriatic acid, and after the fall of the slough, to 
make use of dry cloride of lime (calx chiorinata). The acid most gen- 
erally emplo^-ed is the muriatic. The local treatment proposed by MM. 
Eilliet and Barthez is the following : As soon as the ulcerations assume 
a gangrenous aj^pearance, to touch them with a brush or sponge dipped 
into acid nitrate of mercury, or pure muriatic acid, the brush to remain 
in contact with the sloughs for a few instants, and then to be applied 
rapidl}^ ai'ound and on the parts beyond them. After this cauterization, 
an application is to be made of dry chloride of lime (in the manner rec- 
ommended in the article on ulcero-membranous stomatitis), which is 
to be left in contact with the sloughs for a few minutes, when the mouth 
must be thoroughly washed with a strong jet of water from a syringe. 
The cauterization and use of the chloride of lime are to be resorted to 
twice a day, and the mouth washed three or four times in the interval 
with large injections of simple water, barley-water mixed with honey 
of roses, or better still, with a strong decoction of cinchona. If the 
case goes on favorably, and the sloughs separate, the cauterizations are 
to be suspended, and the chloride of lime alone employed. If, on the 
contrary, a slough forms on the outside of the cheek, a crucial incision 
must be made into it, and a brush charged with the same caustics in- 
troduced between the cuts; powdered cinchona is then placed in the 
openings, and retained there by a piece of diachylon plaster or by 



318 GANGRENE OF THE MOUTH. 

pledgets of charpie, dipped in a solution of soda. This treatment 
is to be continued until the slough separates, when the edges of the 
wound, and all the diseased parts that can be reached, are to be cau- 
tei-ized. 

In apphnng escharotics to the mouth, certain general precautions are 
required, of which it is necessary to give some account. When they 
are used upon the inside of the cheek, a spoon must be introduced into 
the mouth, with the concavity directed towards the alveolar processes, 
in order to preserve the teeth and tongue from being touched. When 
the application is made upon the gums, the cheek should be drawn to 
one side by an assistant, and the tongue pushed out of the way with 
the finger, or a spoon. If the acid happen to touch the teeth or tongue, 
it must be instantl}^ washed off. The mouth ought always to be thor- 
oughl}^ cleansed with water immediately after the cauterization, to re- 
move any superabundance of acid. 

The kind of brush most suitable for the application of the mineral 
acids is one made of charpie, strongly tied to a solid handle. The sponge- 
mop, which is sometimes used, is made by fastening a small piece of 
fine sponge to the end of a stick. 

MM. Guersant and Blache recommend that the acid be applied to 
the slough every hour, until the sphacelus ceases to extend. They 
state that this plan is sometimes advantageous when the gangrene is 
confined to the gums only, but that it is generally powerless when the 
disease has extended to the cheek, or has implicated the deepseated 
tissues. Under the latter circumstances, and when the inefficacy of 
caustic has been shown by trial, they propose the use of the actual 
cautery, as recommended by M. Baron, and other distinguished practi- 
tioners, and which, they add, has afforded them some brilliant results 
in very bad cases. 

M. Barrier advises that we should accurately expose the diseased 
parts by crucial incisions, and apply the escharotic to all the parts 
forming the limits of the gangrene, in such a way that the tissues 
already disposed to slough shall be thoroughly cauterized, w^hile those 
a little bej'ond are so in a less degree. 

In applj'ing these powerful caustics, several authorities recommend 
the administration of an anaesthetic. 

The English writers, and those of our own country, seem rather less 
disposed than the French to make use of powerful escharotics, and 
lay more stress upon the general treatment. Underwood, following 
Dease of Dublin, advises that " the parts should be washed and like- 
wise injected with muriatic acid, in chamomile or sage tea, and after- 
wards dressed with the acid, mixed with the honey of roses, and over 
all a carrot poultice." Dr. Symonds (Lib. of Pract. lied., vol. iii, p. 23) 
directs the cheek to be frequently rubbed with a stimulating embroca- 
tion of camphorated oil and ammonia, on the first appearance of the 
swelling, and in the intervals to be kept moist with a tepid lotion con- 
taining muriate of ammonia and alcohol. On the slightest appearance 
of an eschar upon the interior of the mouth, it is to be touched with 



TREATMENT — LOCAL APPLICATIONS. 319 

solid nitrate of silver, or strong muriatic acid. If sloughing liavc al- 
ready commenced, the nitrate of silver lotion is said to be the best 
application. The month is to be frequently washed or syringed with 
a solution of chloride of soda, and when mortification has taken place, 
we are to endeavor to prevent it from spreading, by carrot or ferment- 
ing poultices. Maunsel and Evanson say that the early application of 
muriatic acid, undiluted, or mixed with one or two parts of honey, is 
the only eiScient application in these forms of gangrene. Dr. Fleming 
{Dublin Hosp, Gaz., May 1st, 1865) recommends the application of a 
concentrated solution of nitrate of copper, to the sloughing surfaces, 
and also paints the circumference of the disease and the surrounding 
cheek with collodion, which, he believes, acts favorably upon the capil- 
lary circulation of the part. Dr. Gerhard (Lib. of Fract. Med., vol. iii. 
Am. ed., p. 2-1) says, "The best local applications are the nitrate of 
silver, if the slough be small in extent ] if much larger, the best eschar- 
otic is the muriated tincture of iron, applied in the undiluted state: 
after the progress of the disease is arrested, the ulcer will improve 
rapidly under an astringent stimulant, such as the tincture of myrrh, 
or the aromatic wine of the French Pharmacopoeia." Dr. Dunglison 
(Prac. of Med., vol, i, p. 36) recommends the application with a brush, 
of a mixture of equal parts of creasote and alcohol, after incisions 
have been made through the gangrenous parts. Dr. Condie {op. cit., 
6th ed., p. 174) states that he has found a strong solution of sulphate 
of copper (thirty grains to the ounce of water), applied very carefully 
twice a day, to the full extent of the gangrenous ulceration, by far 
the most successful lotion. 

AYe have, ourselves, lately employed carbolic acid in two» severe 
cases. The pure acid was carefully applied to the sloughing ulcer on 
the inside of the cheek, and subsequently a solution of one part of 
the acid in fifty of w^ater, was frequently employed to wash out the 
mouth. The application of the undiluted acid seemed to have a bene- 
ficial eff'ect, by checking the progress of the sloughing, and completely 
destroying the putridity of the dead tissue which had not as yet sepa- 
rated. One of the cases recovered quickl}^ without perforation of the 
cheek; but in the other death occurred, with symptoms of profound 
adynamia, though there was little, if any, extension of the gangrene. 

It seems to us very clear, after the study of the treatment recom- 
mended by the different writers quoted above, that the most important 
part of the local management of the disease is the early application 
of some escharotic substance to the ulcerations, or to the mortifying- 
parts ; the best is probably pure muriatic acid. This should be made 
use of twice or three times a day, observing the precaution to wash the 
mouth with water, immediately afterwards, by means of a syringe. 
Later in the disease, when it has extended to the skin, the use of eschar- 
otics, or of the actual cautery, is still recommended by man}^ writers, 
but opposed by others. We confess we should be inclined to prefer, at 
this stage, the use of muriated tincture of iron, as recommended by 
Dr. Gerhard, of carbolic acid as used by ourselves, of strong lotions of 



320 ' GANGRENE OE THE MOUTH. 

sulphate of copper, of solutions of nitrate of silver of moderate strength, 
or of the dressings of muriatic acid and honej^ of roses, as proposed by 
Underwood, in connection with carrot and fermenting poultices, as rec- 
ommended by Underwood and Sj'monds. Throughout the course of 
the disease the mouth ought to be frequently cleansed by washing or 
injecting with solution of chlorinated soda, mixed with eight parts of 
water, or with a dilute solution of carbolic acid, which corrects at the 
same time the terrible fetor of the disease. 

The importance of these measures can scarcely be overestimated, 
since the presence of gangrenous tissue about the oral cavity must lead 
to the introduction of the poisonous results of putrefaction into the 
system, both by the fetid discharges which partly flow down the oesoph- 
agus, and still more by the contamination of the inspired air. Indeed, 
it seems quite possible, as urged by Dr. Keiller (Edin. Med. Jour., April, 
1862), that in cases of unchecked gangrene of the mouth, death occurs, 
in a great measure, from secondary blood-poisoning, resulting from the 
continued and unavoidable inhalation of air poisoned by emanations 
from the gangrenous sloughs. It is evident, therefore, that local appli- 
cations, both of caustics and antiseptic lotions, must be of great service, 
by arresting the sloughing and correcting or checking the foul dis- 
charges. 

General Treatment. — All writers recommend the use of tonics, 
stimulants, and nutritious diet, unless the presence of high fever, or 
the state of the digestive organs, seems to contraindicate their employ- 
ment. From our own personal experience in the treatment of this 
affection ; from a considerat on of what we have seen most successful 
in other forms of gangrene, as that following accidents and surgical 
operations in deteriorated constitutions; from what proved effectual in 
a case or' idiopathic gangrene of the vulva, in a child ten years of age, 
which came under our charge; and from what is necessary in that 
analogous condition of the constitution which accompanies tj^phoid 
and cachectic diseases, we are induced to believe that the general treat- 
ment must be of at least as great importance as the local, and that the 
steady and persevering use of tonics, stimulants, and of the most 
strengthening diet, should always be insisted on from the earliest 
period, whether fever be present or not. The quantity of stimulants, 
and the amount of food, ought, it seems to us, to be measured only by 
the capacity of the digestive organs to receive and assimilate them. 
Of the tonics, the best are quinine and muriated tincture of iron, which 
may be given in syrup, in doses of a grain of the former with from 
three to five drops of the latter, four or five times a day, to a child 
three or four years old. The most suitable stimulants are very fine old 
brandy, Madeira wine given in considerable quantities, and, if the stom- 
ach is sure to receive it well, carbonate of ammonia, or better still, the 
aromatic spirit of hartshorn. The diet must consist of milk made 
into 2^unch with brandy, wine-whey, the yelk of eggs beaten up with 
wine, strong soups and beef tea, animal jellies, and, if the child wish it, 
tender meat finely minced. 



THRUSH. 321 

The room in which the child is placed ought to be large, if possible, 
and at all events thoroughly ventilated. 



AETICLE Y. 



THRUSH. 



Definition; Synonyms; Frequency; Forms. — Thrush, is associated 
with the growth of a peculiar fungus, the oidium albicans (Eobin), and 
appears as a deposit upon the mucous membrane of the mouth, of a 
whitish or grayish-yellow exudation, of a soft cheesy consistence, at 
first adherent, and afterwards spontaneouslj^ detached, and generally 
unaccompanied by ulceration of the tissue beneath. This constitutes 
the whole disease in some cases, no other lesion being discoverable; 
whilst in other instances, and probably in a large majority, it is con- 
nected with some more or less serious general or local disorder. It is 
the disease described under the title of aphthae or thrush, by Underwood 
and Eberle; of aphthae, by Dewees; of erythematic stomatitis, with 
curdlike exudation, by Dr. Condie; and of aphtha lactantium, aphtha 
lactamen, and aphtha infantilis, by the older writers. It is the muguet 
of the French. 

The frequency of the disease is very great in hospitals for children. 
It is common also amongst the children of the poor, and comparatively 
rare in the middle and upper classes of society. It occurs under two 
forms, the idiopathic or jprimary^ and symptomatic or secondary. By the 
first is meant the form in which the affection of the mouth is the only 
perceptible lesion; by the second, that in which disease of other organs 
or of the constitution generally, precedes the buccal exudation. 

Causes. — Predisposing Causes. — The disease occurs at all ages, but 
is by far most common during the first two months of life. Altered 
health from any cause, deficient ventilation^ and want of cleanliness, 
strongly predispose to the production of thrush. Much difference of 
opinion exists as to the nature of the connection between enteritis and 
thrush, especially since the publication of the researches of M. Yalleix, 
who thinks that the latter disease is almost always the consequence 
of the former, and who doubts the existence of purely local cases of 
thrush. MM. Trousseau and Delpech, on the contrary (Journ. de Med, 
de MM. Beau et Trousseau, January, February, April, May, 1845), re- 
port 14 cases out of 58, in which there was neither gastric nor intesti- 
nal complication, and others in which enteritis did not occur except as 
a consequence of thrush. They state, however, that though enteritis 
does not exist in all cases, and is a simple complication in others, it is 
sometimes the true cause, the sole origin of the disease. Again, Dr. 
Berg, in a very accurate and careful history of the disease (Brit, and 

21 



322 THRUSH. 

For. Med. Rev., October, 1847, p. 429), in which he demonstrates its 
cryptogamic nature, states " that both the local and general sj'mptoms 
which accompany thrush in the child are, in most cases, immediate 
or secondary consequences of the presence of the parasite, and not 
to be regarded as the causes of that fungoid vegetation." It is be- 
lieved by many observers to be contagious. This opinion is rendered 
doubtful, however, by the assertion of MM. Baron, Billard, Guersant, 
and Yalleix (hoc. cit., t. iv, p. 63), that they have known children in 
health to be fed with the same spoon which has been used for others 
affected with the disease, without their contracting it. M. Bouchut, on 
the contrary, and Dr. Berg (loc. cit.'), both of whom believe in the crj'p- 
togaraic nature of thrush, assert it to be contagious. Dr. Berg is of 
opinion that it is "conveyed from one patient to another by sporules 
or fragments of sporules, in the dried state, floating in the atmosphere, 
but that still more frequently it is proj^agated by the bottles from which 
children with thrush have been fed, or by the nipple, especially where, 
as in many hospitals, two children are suckled by one nurse." This 
gentleman made many experiments in order to decide this question, all 
^of which proved favorable to the idea of contagion. 

Of various predisposing causes which have been cited as productive 
of the disease, the ones most generally admitted are the use of artificial 
diet, particularly one consisting of farinaceous substances, and, in chil- 
dren who are suckled, an unhealthy state of the nurse's milk. To show 
the truth of these assertions, I make the following quotations. Under- 
wood says : '^A principal remote cause of this disease seems to be indi- 
gestion, whether produced by bad milk, or other unwholesome food, or 
by the weakness of the stomach." Dewees remarks that " children fed 
much upon farinaceous substances are especially exposed to the attacks 
of this disease, particularly when their food is sweetened with brown 
sugar or molasses." Dr. Eberle says : " Unwholesome and indigestible 
nourishment, and overdistension of the stomach, during the early stages 
of infancy, almost inevitably lead to the occurrence of aphthae (thrush). 
Bad and old milk, and thick farinaceous preparations sweetened with 
brown sugar or molasses, are es2:)ecially apt to give rise to the dis- 
ease." Much influence is ascribed by Dr. Berg to the operation of arti- 
ficial food in favoring the growth of thrush. M. Yalleix (^loc. cit., p. 60), 
who has studied the subject with the greatest care and attention, says 
that amongst the hj^gienic conditions which may act as predisposing 
causes " one alone has seemed to me to exert a positive influence, and 
this is improper alimentation.'' He adds, that since the publication of 
his Clinique, he has several times met with cases of thrush, " and I have 
always found that the children had been put upon feculent diet. On 
the other hand, I have never known a child to have the disease, who 
had been suckled exclusivel}^ during the early months of life." MM. 
Trousseau and Delpech, in the very valuable paper on muguet (thrush), 
already quoted, say: "We would be justified, therefore, in asserting, 
that we have never known an infant to die of thrush, who had been 
suckled at a healthy breast, or whose health had not been danger- 



ANATOMICAL LESIONS. 323 

ously compromised by other causes." To show in another mode the 
influence of this cause, we will state that of 29 cases of the disease ob- 
served by these gentlemen in children who were suckled, only 7, or 
one-fourth, died; whilst of 22 in those who were not suckled, 17, or 
more than three-fourths, died. Oar own experience is precisely that 
of MM. Yalleix, Trousseau, and Delpech. 

Season exerts a considerable influence upon the production of thrush, 
as M. Yalleix found that more than half the cases occurred during the 
three warmest months of the year. 

Exciting Causes. — The deprivation of the breast, and a consequent 
resort to artificial diet, particularly one consisting of farinaceous sub- 
stances, is probably much the most frequent exciting cause of thrush. 
An unhealthy state of the milk of the nurse will also act as an exciting 
cause. We have met with two cases of the disease, one of them fatal, 
which appeared to depend upon the latter circumstance. Dr. Berg 
believes that prolonged sleep from any cause disposes to the disease, 
by favoring the growth of the parasite, or by so changing the secre- 
tions of the mucous membrane of the mouth, as to render them impor- 
tant agents in augmenting the disorder. An acid state of the buccal 
secretion is cited as a (;ause by many authors, and is clearly proved to 
exist in a great many instances. 

Anatomical Lesions. — The characteristic deposit is found upon the 
mucous membrane of the mouth, pharynx, oesophagus, and in rare 
cases, of the stomach and intestines. The question of the possibility 
of the extension of thrush to the gastric mucous membrane has been 
much discussed, and the highest authorities have been almost equall}^ 
divided upon it. This disagreement has arisen solely from the want 
of microscopical examination, which enables the observer to distin- 
guish readily between true thrush and other appearances of the gas- 
tric mucous membrane which closely resemble it. The most conclu- 
sive demonstration of its occurrence upon the mucous membrane of the 
stomach has been recently furnished in a valuable article on this sub- 
ject, by M. J. Parrot {Arch, de Physiologie Norm, et Path., Nos. 4 and 5, 
1869) ; and in a still more recent article (id. op., vol. iii, 1870, p. 621), 
he has also determined the possibility of its development in the large 
intestine. It is a curious fact^ and a very important one, insisted upon 
by MM. Trousseau and Delpech, and other observers, that the false 
membrane never extends to the nasal or air-passages; and they call 
attention to the singular difference in this respect between the affection 
under consideration and diphtheritic inflammation, which attacks almost 
exclusively the nostrils, pharynx, larynx, and bronchia. It appears, 
however, from recent observation, that the peculiar growth of thrush 
has been found upon both the epiglottis and the inferioK vocal cords ; 
and Parrot (loc. cit.) gives the details of a case in which the fungus was 
found in the air-vesicles of one lung. 

Lesions of the digestive mucous membrane are met with in nearly 
all the cases. M. Valleix states that softening of the gastric mucous 
membrane is almost constant, and that it is often accompanied by red- 



324 THRUSH. 

ness and thickening. The authors cited above are of opinion that the 
gastric lesions have been greatly exaggerated, and assert them to be 
much the same as exist in other diseases foreign to the digestive appa- 
ratus. Yarions morbid alterations of the mucous membrane, of the 
intestines exist in nearly all fatal cases. This fact is acknowledged as 
well by MM. Trousseau and Delpech, who deny the invariable connec- 
tion of these alterations w^ith thrush, as by M. Yalleix, who asserts the 
connection almost without reserve. In nearly all cases the mucous 
membrane of the large intestine presents some of the following lesions, 
which are mentioned in the order of their frequency : thickening, injec- 
tion, softening, or ulceration. In the ileum are found, in a great man}^ 
cases, injection, softening, or thickening of the mucous membrane, un- 
usual development of the mucous follicles, and tumefaction and ulcera- 
tion of the glands of Peyer. 

In severe symptomatic cases a certain amount of erythematous in- 
flammation is commonly found upon the skin of the buttocks and 
thighs, and ulcerations sometimes exist upon the inner ankles. Traces 
of inflammation sometimes, but very rarely, exist in the membi'anes 
of the brain, and the lungs not unfrequently present the lesions of sec- 
ondary pneumonia. Before leaving this part of the subject, we may 
remark that in the few cases we have met with in private practice, no 
ulcerations occurred upon the malleoli^ and the erythema was observed 
only in the neighborhood of the anus. 

Dr. Dewees describes the autopsy of a child who died about the end 
of the first month of life, of what he designates as aphthae. The lesions 
coincide so closely with those which are characteristic of thrush, that 
we will quote the descri2)tion, in order that the two may be compared 
together by the reader. "We found the whole tract of the oesophagus 
literally blocked up with an aphthous incrustation, to the cardia, and 
there it suddenly stopped. The inner coat of the stomach bore some 
marks of inflammation, as did several portions of the intestines ; but 
not a trace of aphthae could be discovered below the place just men- 
tioned." In the previous description of the case, he says that coat 
after coat of aphthae were thrown ofl", and each new crop appeared to 
be more abundant, and less amenable to remedies. (^Dewees on Children, 
p. 304-305.) 

Dr. Eberle saj^s: "I have myself had an opportunity of examining 
the body of an infant, that had died of this disease (aphthss or thrush). 
In this case the aphthae were very distinct, throughout the whole 
course of the oesophagus. The stomach and bowels presented nothing 
that bore any resemblance to this eruption; but there were decided 
marks of inflammation in the mucous membrane of the small intestines, 
with a vast number of minute superficial ulcerations, and larger patches 
of softening of this tissue, throughout the colon and lower part of the 
rectum." (Diseases of Children^ p. 172-173.) 

Symptoms. — We shall first describe the characters of the exudation, 
and then proceed to the consideration of certain general and local 



ANATOMICAL APPEARANCES. 325 

phenomena ^yhieh exist to a greater or less extent in both forms of the 
disease. 

The mucous membrane of the mouth is often somewhat red, dry, 
and tender for a longer or a shorter time (generallj^ from one to three 
days), before the appearance of the exudation, and at the same time 
the papilh^ of the tongue swell and become protuberant. Next the 
exudation shows itself in the form of small, whitish points, sometimes 
on the tongue first, and in other cases on the inside of the lips, whence 
it extends to the cheeks in idiopathic mild cases, and to the roof of the 
mouth, soft i^alate, pharynx, and oesophagus, in the grave sj^mpto- 
matic form. The points of false membrane first deposited rapidly in- 
crease in size and thickness, so that in from one to three or four daj^s, 
they assume the form of large patches, or a continuous membrane, 
which covers the \\«hole or a considerable portion of the cavity of the 
mouth. When the exudation is recent, it is thin, and its surface 
smooth; when, on the contrary, it has been longer deposited, it be- 
comes thicker, and its surface is rough. It is at first of a milk-white or 
pearly hue, but when undisturbed assumes a grayish or yellowish 
color. It is soft in consistence, breaking down under the finger like 
cheese, and presenting no traces of organization to the naked eye. It 
adheres to the mucous membrane with considerable tenacity at first, 
but becomes looser after awhile, and is detached spontaneously at last 
w^ithout any lesion of the tissue beneath. 

The foregoing description applies to the exudation as it appears to 
the unassisted eye. We pass next to give an account of the characters 
it pi-esents, when subjected to microscopical examination, and in so 
doing f^hall quote the language of Berg, who first discovered that thrush 
essentially depended upon the presence of a peculiar parasitic fungus, 
to which Eobin has given the name of oidium albicans. Dr. Berg {loc. 
cit.) states, that the white coating of the exudation consists of epithe- 
lium, thickened by the swelling of its constituent cells; from the epithe- 
lium there springs a parasitic fungus in greater or less quantity, so 
that the chief portion of a patch of aphthae (thrush) is composed either 
of epithelium or else of the parasitic growth. Under a magnifying power 
of from 200 to 300 diameters, an aphthous crust is seen to consist of 
epithelial cells, with a more or less interwoven coat of fibres, and a 
variable number of spherical or oval cells, without s^wj sign of exuda- 
tion-corpuscles, but only a small quantity of molecular albuminous de- 
posit. "We can often trace the successive development of these cells 
from a spherical one of the smallest size, to an oval cell, and thence to a 
filament- and we have no doubt ourselves that the smaller cells are 
sporules, out of whose development the larger oval cells are formed, 
and finally, the filaments in the same manner as has been observed in 
other fungoid growths of this nature/' Numerous projecting fibrils 
are observed in the circumference of an aphthous crust when sub- 
mitted to the microscope; but these are rendered infinitely more clear 
by a weak solution of potash, which dissolves the albumen, and renders 
the cells of the epithelium transparent, while, at the same time, it 



326 THRUSH. 

diminishes their intimate cohesion, and the network of vegetable fibres 
is more plainly seen. "These fibres are cylindrical, with sharply de- 
fined dark edges, and their centres are transparent in transmitted 
lightj they are generally equal in thickness, but at times they are, as 
it were, knotted together, and divided by distinct walls of separation. 
.... In their interior, these fibrils often exhibit nucleated cells; 
occasionally these are very numerous, and of small size, but at times 
they are larger. In their course the fibrils divide into numerous 
branches, whose diameter is not less than that of the original stem, 
and I have occasionally observed these ramifications to increase in 
thickness, at their free extremity, and to terminate in a club-shaped 
end with a species of cell. From the sides of the fibrils spring nu- 
merous sporules, forming a point of departure for new ramifications. 
.... Careful investigation has shown us that tbese cells are placed 
upon the sides of the fibrils, and in particular that they are congregated 
around the terminations of the latter. It must, therefore, be admitted 
that the cells and the fibrils are both constituent parts of one and the 
same organization. When this growth vegetates undisturbed, its fibrils 
penetrate between the layers of the epithelial cells, but do not extend 
deeper than the inferior layer, though they spread laterally in every 
direction. On the free surface of the epithelium, the ramifications rise 
above the surface, exhibiting at the same time an abundant fructifica- 
tion, which gives a yellowish hue to the exterior." 

M. Parrot, in describing the appearances of thrush upon the gastric 
mucous membrane, states that the disease presented itself in the form 
of small prominent rounded masses, of yellowish color, and either iso- 
lated or in groups. These were adherent to the mucous membrane, 
nearly all umbilicated, and upon pressure the central depression be- 
came filled with a cheesy-looking material. On microscopic examina- 
tions of sections, the spores and filaments of the muguet were found 
infiltrating the tissue, and as it were planted there, at times scattered in 
small numbers, at others accumulated in large masses, and holding be- 
tween them many oil-drops and some debris of the mucous membrane. 
The muscular coat of the stomach was not involved, but in some in- 
stances the spores and filaments penetrated the mucous membrane, and 
extended to the submucous space. In other cases the mucous membrane 
was only superficially involved. 

The reader is referred for a more full account of the cryptogamic 
theory of thrush to the interesting review of Berg's work above quoted, 
and to Bouchut's work on the diseases of new-born children ; and for 
a complete description of the oidium albicans to the work of Eobin, 
Histoire Naturelle des Vegetaux ParaszYes, Paris, 1853; the articles of 
Parrot above quoted ; and the article on Thrush in Yogel's work on the 
Diseases of Children (Amer. ed., 1870, p. 99). 

Symptoms of the Mild Form of Thrush. — This form is the one most fre- 
quently met with in private practice. It is mild in all its characters, 
and often presents no other symptoms than those connected with the 
mouth. These are heat and dryness, with tenderness of that part. The 



¥ 



SYMPTOMS. 327 

tenderness is shown by tbe child's crying and jerking the head back- 
wards when the finger is introduced into the mouth, whereas, in health, 
the infant will almost always seize the finger and suck it with consid- 
erable force. It is shown, also, by the refusal to take the breast, or by 
the diflSculty with which this is dune, the child occasionally letting the 
nipple drop with a cry of pain, then seizing it again, and again drop- 
ping it with fretting or screaming. In some of the cases there are va- 
rious signs of disorder of the digestive tube, which are, however, seldom 
severe. They consist of slight diarrhoea, the stools being at first yellow, 
and afterwards green and acid ; of occasional vomiting, of attacks of 
colicky pain, and sometimes of feverishness. To show how frequent 
is the occurrence of diarrhoea in thrush, and to prove also that it is not 
a necessary accompaniment of the disease, as has been supposed by 
some persons, we will quote the fact mentioned by Dr. Berg, that of 115 
cases, in only 29 did the stools retain the normal yellow color through- 
out the whole course of the disease; while in the remaining 86, green 
evacuations appeared simultaneously with the invasion, or supervened 
at a later period. We may cite also the cases reported by MM. Trous- 
seau and Delpech, of which only 14= out of 58 presented neither gastric 
nor intestinal complications. 

The amount of exudation is generally small in this form, and it rarely 
extends behind the soft palate. The duration is usually between four 
and nineteen days, the average being about eight or twelve. The ter- 
mination is almost always favorable. 

Grave Form. — It is under this form that the disease is most apt to 
occur in public institutions for children, and particularly in foundling 
hospitals. That it sometimes occurs, also, in private practice, will not 
be doubted, we think, by any who will read with care the descriptions 
of the disease given by Underwood, Dewees, and Eberle. We have 
ourselves met with two fatal cases in private practice, which presented 
all the symptoms described by M. Yalleix as characterizing those ob- 
served by him in the Foundling's Hospital at Paris, with the single ex- 
ception of the ulcerations upon the internal malleoli. They were both 
children of parents who had every comfort at their command. One 
died at the age of four weeks, in consequence of the attempt to rear it 
on artificial diet. The other perished w^hen six weeks old, apparently 
from some unhealthy condition of the mother's milk, which seems the 
more probable from tbe fact that the same mother had previously lost 
two children under precisely similar circumstances; all the children of 
this person were born vigorous and hearty, and did well for a short 
time, but .soon after the birth, the nipples of the mother became dread- 
fully excoriated, the digestive organs of the infant began to give way, 
and death finally occurred with all the symptoms of fully developed 
thrush. We can surmise now, though no examination was made at the 
time, that the cause of the disease was a continuance of colostrum-cor- 
puscles in the mother's milk. 

The most important symptoms of the grave form are the buccal exu- 
dation, various abdoyninal symj)toms, particularly diarrhoea, vomitings 



328 THRUSH. 

and colic, and more or less marked fever. The order of succession of 
the symptoms in severe thrush is not always the same. In most of the 
cases the first symptom observed is, probably, diarrhoea, which is soon 
followed b}^ fever, and in a few days by the appearance of the false 
membrane in the mouth. In a smaller number of instances the buccal 
exudation is the first symptom observed. The characters of the exu- 
dation are much the same as those observed in the mild form of the 
disease, except that the membrane is thicker, covers a larger portion 
of the mouth, and generall}^ extends to the pharynx and oesophagus. 
In addition to the plastic deposit, there sometimes exist, especially in 
very bad cases, ulcerations upon the roof of the mouth, fr^num linguee, 
and gums. These are generally few in number, and either confined to 
the mucous tissue, or they may extend to the fibrous texture beneath; 
the surface upon which they rest is generally softened in consistence; 
their edges are irregular, soft, and of a whitish or reddish color. The 
heat of the mouth is not generally increased, except in very severe 
cases; the mouth is moist at first, but afterwards becomes very dry, 
and, from the refusal to suck the finger when it is introduced between 
the lips, and the difiiculty with which the acts of suckling or feeding 
are performed, is evidently tender and painful. 

The symptoms depending on the enteritic affection, are tenderness of 
the abdomen, diarrhoea^ vomiting, and fever. The abdomen is usually 
distended by flatulent collections in the bowels, and is more or less pain- 
ful to the touch, particularly in the right iliac fossa and epigastrium, 
and in severe cases over its whole extent. At the same time the child 
evidently suffers from colicky pains, as shown by restlessness, by uneasy, 
twisting movements of the trunk, b}" kicking of the limbs, and by cry- 
ing, particularly just before or at the moment of the evacuations. The 
appetite is usually diminished or entirely lost. The diarrhoea -comes on 
gradually, the stools retaining their natural color at first, and being 
merely thinner and more frequent than natural. As the case jjrogresses, 
they become more and more liquid and numerous, and almost invariably 
of a bright green color, and very acid. The green color of the dis- 
charges, and their highly acid condition, is noticed by all observers. 
Vomiting occurs in many of the cases, but is less frequent than diar- 
rhoea. In some instances it is very obstinate and distressing, causing 
the rejection of whatever alimentary substances the child may take. 
Under these circumstances it has often been observed to coincide with 
the presence of a great deal of exudation upon the base of the tongue 
and soft palate, which has been supposed to act as its exciting cause. 
In other instances it is not so frequent, and as the matters ejected con- 
sist of greenish or yellowish bile, while, at the same time, the epigas- 
trium is very sensible to pressure, this form of vomiting has been 
thought to depend upon gastritis. 

Fever exists in most cases, from the time that diarrhoea makes its ap- 
pearance, and sometimes at an earlier period. It is at first moderate, 
but as the case goes on, often becomes intense, the pulse rising gradu- 
ally from 80 to 90, or 120, 140, and even 160. The heat of the surface, 



SYMPTOMS — NATURE OF THRUSH. 329 

especially of the abdomen, is much increased, and accompanied by dry- 
ness. The feverish condition of the system is shown also b}" the rest- 
lessness and fretting of the child, and often by loud, frequent crying. 
AVhen the exudation extends into the pharynx, the cry usually becomes 
hoarse and indistinct. 

There are two other symptoms which occur in the course of thrush, 
about Avhich some discussion has arisen. These are, the appearance of 
an erythematous redness about the anus, and upon the buttocks, genitals, 
and upper parts of the thighs, and ulcerations upon the internal malle- 
oli. The erythema is stated by M. Yalleix to precede the other symp- 
toms in the greater number of instances, whilst MM. Trousseau and 
Delpech deny the correctness of the assertion, and observed it to follow 
the diarrhoea in the majority of their cases. It seems to us that the 
latter authors are correct in ascribing the erythema to the irritation 
produced by the contact of the urine with the skin, which is predis- 
l^osed, by the cachectic state of the constitution, to take on inflam- 
mation from causes which would not affect it in a healthy subject. The 
erythema is sometimes followed by papules, vesicles, blebs, and ulcer- 
ations, all of which probably depend upon the cause just referred to. 
The malleolar ulcerations are ascribed to the friction of the ankles 
against each other, a cause sufficient to produce such an effect in a 
broken-down, diseased constitution, though insufficient in a healthy one. 
AYe may mention that we have seen the erythema frequently in private 
practice, but never the malleolar ulcerations. 

During the acute 2:>eriod of the disease, the strength of the child is not 
much diminished, but as the case approaches its termination, if no 
favorable change takes place, the patient becomes weak and exhausted; 
the face assumes a pale and sallow look; the features are sharp and 
defined, and the eyes dull and surrounded by bluish circles. ^At the 
same time the whole body becomes emaciated, the skin loses its elas- 
ticity, and hangs in folds or wrinkles upon the limbs, and the surface 
assumes a dark and dingy hue. As the fatal termination approaches, 
all restlessness ceases, and the child lies profoundly still, or only moves 
the mouth from time to time, or utters a faint cry; the diarrhoea dimin- 
ishes, and the vomiting generally ceases; the pulse becomes very rapid 
and weak, the extremities cold, and death occurs in the midst of pro- 
found quiet, or after a few slight convulsive movements. The duration 
of this form of the disease is very uncertain. It is often less than that 
of the mild form, since many children die in the first five days after the 
appearance of the exudation. In other cases it is much longer, from a 
few weeks to two months. Eelapses are not uncommon. 

Before closing our remarks upon the symptoms, it is proper to state 
that the disease sometimes occurs at the termination of acute local 
affections, as pneumonia, bronchitis, or pleurisy, under which circum- 
stances there will be, in addition to the symptoms peculiar to thrush, 
those of the malady which preceded it. 

Kature OF THE Disease. — Eepeated microscopic examinations have 
so uniformly confirmed the statements of G-ruby and Berg, that it is 



330 THRUSH. 

no lono-er doubtful that a peculiar parasite, oidium albicans, is a con- 
stant element in the exudation of thrush. It is, however, far from 
being so well determined what relation this growth bears to the dis- 
ease; since, while one class of authorities consider it the essential and 
sole cause of the other local and general symptoms, another regard it 
merely as an epiphenomenon, the spores of the parasite finding a suit- 
able nidus for development on the already diseased mucous membrane. 
Fortunately^, the solution of this question is of no very great practical 
importance, as the causes of the disease are well ascertained, and its 
prophylactic and curative treatment will not be aifected by the view 
entertained. 

Diagnosis. — The diagnosis of thrush is rarely difficult. Aphthae 
differ from it in their vesicular nature during the formative stage, in 
the ulcerations which follow the vesicles, and in the absence of false 
membranes. From ulcero-membranous stomatitis it may be distin- 
guished, by the formation in that disease of false membrane in layers 
from the beginning; by the presence of ulcerations; by the spongy, 
bleeding state of the gums ; by the fetid breath ; by the absence of the 
abdominal symptoms which exist in thrush; and by the microscojDic 
appearances of the deposit. 

Prognosis. — The prognosis must depend, in great measure, upon the 
circumstances under which the disease occurs. In private practice, 
and whenever the patients are suckled by their own mothers, or by 
healthy nurses, it is a mild affection. But in foundling hospitals, on 
the contrary, where the children are mostly brought up by hand, it is 
one of the most fatal maladies to which children are subject. The 
prognosis varies according to the form of the disease. The mild form 
is rarely fatal^ w^hile the grave form is fatal in the great majority of 
the cases. 

To show the frightful severity of the disease under certain circum- 
stances, we maj^ mention that of 140 cases which occurred in the 
wards of M. Baron, at the Foundling's Hospital of Paris, only 29 
recovered; while of 22 cases observed by M. Valleix, in the same hos- 
pital, but 2 recovered (Yalleix, loc. cit., p. 74). Again, M. Bouchut 
states that of 42 cases observed hy himself, at the Necker Hospital, 14 
were of the idiopathic (mild) form, all of which terminated favorably; 
and 28 of the grave or symptomatic form, of which 20 died, and 8 left 
the hospital still laboring under the disease. Of the 20 fatal cases, 12 
presented the lesions of chronic entero-colitis, 4 of acute entero-colitis, 
8 of pneumonia, and 1 of hydrocephalus. It may be stated, in conclu- 
sion, that the danger is greatest, in private practice, when the attack 
occurs in a child fed on artificial diet; when there is reason to suspect 
an unhealth}^ state of the nurse's milk; and in proportion to the extent 
and quantity of the exudation, its resistance to treatment, and the 
severity and obstinacy of the abdominal symptoms. 

Treatment. — Prophylactic Treatment — The most certain means of 
preventing thrush are evidently to procure for the child a full, healthy 
breast of milk, to give it a good habitation, to secure for it perfect 



GENERAL TREATMENT — DIET. 331 

cleanliness, and to attend properly to its clothing. When it is impos- 
sible, from any cause, to obtain a nurse for the child, the diet ought to 
be most carefully regulated as to quality, quantity, and times of admin- 
istration. Careful attention to these points will, and, we doubt not; 
have, greatly diminished the frequency and lessened the severit}^- of the 
disease in private practice. 

General Treatment. — It is clear that the successful management of 
thrush must depend much more upon judicious regulation of the hygiene 
of the child than upon any therapeutical system that can be devised. 
The most frequent cause of the disease is, as we have seen, artificial 
diet, especially one in which milk is sparingly used or excluded, or an 
unhealthy state of the nurse's milk. It is reasonable to conclude, 
therefore, that attention to the removal or mitigation of these and 
other unfavorable hj'gienic conditions, constitutes the most important 
indication of treatment. 

If a child who has been attacked with thrush is suckled exclusively, 
the milk of the nurse ought to be subjected to chemical and microscopic 
examination ; and should it be found to present unhealthy characters, 
another nurse ought to be procured as soon as possible. In all such 
cases the nurse must pay strict attention to her diet, avoiding all arti- 
cles which she knows or suspects to disagree with her, and all very 
rich dishes. Dewees recommends that she should abstain from most 
common vegetables, except rice, and from all kinds of liquors, especi- 
ally the fermented. 

When the disease occurs in a child who is nursed and fed alternately, 
and the remark about to be made applies still more appropriately to 
one fed entirely upon artificial diet, the most important remedy in the 
case is to procure a good wet-nurse. This is far better than any med- 
ical treatment that can be instituted. Often, however, this is impos- 
sible, and, under such circumstances, the regulation of the diet ought 
to be attended to with the utmost care by the physician himself, who 
should specify its material, quantity, and mode of preparation. 

As we shall be obliged constantly to refer to the proper diet for 
young children in our future articles on diseases of the digestive organs, 
and indeed all through this work, we think it will be best to make 
some general and extended remarks on the subject here, where we first 
meet with a disease the cause of which is almost always improper 
food, and the cure of which is the abandonment of a faulty, and the 
substitution of a proper aliment. 

In the first place, we wish to repeat the statement already made, 
that the breast gives the only food for infants which can be relied on 
as the correct one. This may seem very much like saying that white 
is white, and red is red, or that two and two do indubitably make 
four; indeed, to ourselves it seems utterly superfluous, but we have 
known so many medical men, men in authority in the nurserj^, and 
such hosts of fathers and mothers, who cannot be made to believe this, 
that we feel compelled to reiterate our own individual opinions as 
strongly as possible. But cases do constantly occur in which a young 



332 THRUSH. 

infant must be wholly or in part fed artificially, and here we have to 
recommend some substitute for breast-milk. In this city, ass's milk, 
which is conceded to be more like human milk than that of any other 
animal, cannot be had, and we are forced to take cow's or goat's milk. 
The latter is not so common as to be readily obtained, and practically 
we are driven to the use of the former. 

In choosing cow's milk, the first thing to be thought of is the purity 
of the milk. In small towns and in the country it is very easy to ob- 
tain fresh pure milk, but in large cities it is often verj^ difficult. Still, 
with due care and diligence, and money, it can generally be done. 
Our own practice has always been to choose a milkman who himself 
brings milk from a farm, or w^ho, at least, employs himself the man 
who delivers it. We never have, and never shall, so long as we can 
help ourselves, take milk from those middlemen who buy it of anj^body 
that may have it to sell. Moreover, the person who has charge of the 
child should always, if possible, know the milkman personally", and 
know exactly where he comes from, and what manner of man he may 
be. An honest farmer or dairyman who pastures and feeds his own 
cows on a healthy farm is the man to be employed to furnish milk to 
the poor little baby who has to seek another dairy than his own 
mother's. If the character of the milkman is not a sufficient guaran- 
tee, or if, from any accident, the milk has to be changed, or if any 
doubt arises as to its quality, there are some simple methods of judg- 
ing which can be made use of by any person of ordinary intelligence, 
and which will reveal any gross deception on the part of the milk 
vender. 

A good specimen of cow's milk ought to be slightly acid or neutral; 
it should contain a certain average proportion of cream, and it should 
have a certain average density. 

These points may be ascertained with sufficient accuracy to guide us 
in our choice or refusal of any sample of milk, in the following mode : 
Litmus-i)aper turns red when touched by any acid; a very weak acid 
will do this. If a good sj^ecimen of litmus-paper (which can be pro- 
cured of the apothecary) turns faintly red when dipped into milk, the 
milk is properlj" acid; if turned bright red, the milk is too acid. When 
no change is produced on the litmus-paper, the milk is either neutral 
(which is sometimes the case with healthy milk), or it is alkaline. To 
determine whether it be neutral, turmeric-paper, which is turned brown 
by alkaline solutions, must be used. If the specimen is found to be 
alkaline in a marked degree, either the cow is diseased in all proba- 
bility, or some alkali has been added to the milk. 

It is a curious fact that Dr. Parkes {3Ianval of Practical Hygiene, 2d 
ed., London, 1866) is almost alone in asserting that healthy cow's milk 
is either faintly acid or neutral. Most authorities assert that it is al- 
kaline. In order to determine this matter for ourselves, we tested the 
milk of thirt3^-one fine cows, fed on the finest pasturage in the neigh- 
borhood of this city. This was done by taking the milk, just as it was 



MODE OF TESTING MILK. 833 

drawn from each aniraal, separate!}" in the milking-hoiise, and testing 
at once with the best litmus-paper. In all the paper was turned red 
more or less distinctly. Dr. John Ashhurst, of this city, tested for us, 
with both litmus- and turmeric-paper, the milk of nine fine Durham 
and of four Alderney cows, belonging to his father, all on the finest 
pasturage. He says that in one Durham and in one Alderney the milk 
appears to have been almost neutral, and in all the rest more or less 
acid.- In testing the milk of another Durham, litmus-paper was red- 
dened, whilst the turmeric w^as also slightly changed, but he supposed 
the latter change to be due to a greasy condition of the milk, owing to 
the fact that the cow was in the latter period of a long lactation. 

To determine the proportion of cream, we may make use of a glass 
vessel, made of a section of a cylinder, tall, and not too wide, and grad- 
uated to inches, with the upper inch divided into hundredths, or a 
French glass divided into centimetres, such as ma}^ be found in the 
shops for the sale of chemical apparatus. This is to be filled to the 
upper mark w^ith milk, and put aside for twenty-four hours; at the end 
of that time the cream will have separated and risen to the top, and its 
proportion can be read off on the graduated scale. According to Dr. 
Parkes, the cream should be from 4 to 6 per cent. In the milk of Al- 
deruej" cows, it will reach 30 to 40 per cent. This seems to us too large 
a proportion for the use of children. 

We think, however, that the average of cream given by Dr. Parkes 
is probably ratlier too low. The Maison Bustique, a French work of 
very high authority on agriculture, states (tome iii, p. 61) that the milk 
of cows, of good race, well kept, furnishes 15 per cent, of cream. The 
milk supplied by the milkman employed by one of us gave 14 per 
cent, of cream on one occasion, and 10 at another. The specific grav- 
ity of the former specimen was found to be 1029. Of three other speci- 
mens, bought at hazard, of different dealers, the proportion of cream 
was 7 per cent., 6 per cent., and 14 per cent., respectively. We are 
disposed to think, therefore, that families ought to endeavor to procure 
milk containing at least 10 per cent, of cream. 

We next have to ascertain the density, in order to determine the 
proportion of water. The most common adulteration of milk is, of 
course, with water, to increase its quantity, and so augment the profits 
of the salesman. The density or specific gravity, let it be remembered, 
is no safe guide as to the proportion of cream. That must be settled in 
the mode just described. But the density gives the proportion of 
water. The specific gravity of good, pure milk is given by Dr. Parkes 
at 1030.5, or 1026, at a temperature of 60° Fahr. We found it in an 
excellent specimen to be 1029. Dr. Parkes found that w^hen, in milk 
of the specific gravity above mentioned, one part of water was added 
to nine of milk, the specific gravity fell to 1027 or 1023; when three 
parts of water were added to seven of milk, it fell to 1021 or 1017.5; 
and when five parts of water to five of milk, it fell to 1015. These 
were the proportions obtained by several experiments. 

We found that the specific gravity of a specimen of excellent milk, as 



334 THRUSH. 

ascertained by a h^^drometer^ was 1028. When to this milk was added 
one-fourth part of water, the specific gravity fell to 102-i, and when a 
half had been added it fell to 1020. In another specimen, the specific 
gravity, obtained in the same way, was 1030 at a temperature of 64° 
Fahr. When to this specimen one-half water was added, the specific 
gravity fell to 1020. 

By these three simple methods of examination, the aciditj" or alka- 
linity of the milk, the proportion of cream, and the proportion of water, 
can be determined. If the milk is either strongly acid or alkaline, it 
is not to be trusted. If it be strongly acid, it has undergone the acid 
fermentation, and is not fit for use. If it be strongl}^ alkaline, it has 
either been adulterated by the addition of an alkali, probably, accord- 
ing to Dr. Parkes, carbonate of soda, to prevent or arrest the lactic 
acid fermentation, or it may have been taken from a diseased cow. 
Dr. Parkes suggests the latter probability in a doubtful way. Dr. J. 
F. Simon, of Berlin (Animal Chemistry with Reference to the Physiology 
and Pathology of Man, vol. ii, p. 67), states, that he analyzed milk drawn 
from the teat of a cow having vaccinia, and found it strongly alkaline, 
and showing with the microscope mucus- and pus-corpuscles, while that 
drawn from a healthy teat had a mild acid reaction, and contained no 
pus- or mucus-corpuscles. He also states (page 68), that Herberger 
has analyzed the milk of cows suffering from the grease, and found it 
to contain an increased quantit}' of the alkaline salts, in the first stage; 
in the second stage it was thick and viscid, and had, besides, an un- 
pleasant and putrid taste and smell. In both stages, the presence of 
carbonate of ammonia (an ingredient never before observed in the 
milk) was detected. 

The most common adulteration of milk is with water. The mode of 
detecting this, by ascertaining the sj^ecific gravity, has already been 
given. Starch is sometimes used to thicken a thin milk. The micro- 
scope will detect this by showing the j^resence of the starch-granules. 

The mother will often wish to preserve milk, especially in our hot 
summer weather, or for a few days, when on a journey. The best 
preservative in hot weather, for the day, is of course a good ice-chest. 
Dr. Parkes says that when boiled, "the bottle quite filled, and at once 
corked up and well sealed, the milk lessens in bulk, and a vacuum is 
formed above. It will keep thus for some time. A little sugar aids 
the preservation. If the heat is carried in a close vessel to 250° Fahr., 
the milk is preserved for a vevj long time, even for years; the butter 
may separate, but this is of no consequence;" or, if a little carbonate 
of soda and sugar is added, without boiling, he says it will keep for 
ten days or a fortnight. Cooley, in his Cyclopaedia of Practical Receipts, 
states, that the addition of ten to twelve grains of carbonate, or bicar- 
bonate of soda, to each pint of milk, will preserve it for eight or ten 
days in temperate weather, and adds that this addition is harmless, 
and, indeed, is advantageous to dyspeptic patients. The method of 
boiling, proposed by Dr. Parkes, is the one now so much used for pre- 
serving fruits fresh. 



MODE OF PREPARING MILK, AND QUANTITY TO BE TAKEN. 335 

HaviDg determined upon the use of cow's milk, we have next to con- 
sider its mode of preparation. 

It should never be given pure to young infants, at least such is our 
clear conviction. We still believe that the old rule, of two parts of 
water to one of milk, is the proper one during the first month. We 
know that some of the more recent writers, and not a few of the phy- 
sicians of this city, now order half water and half milk, and some chil- 
dren do well on that proportion; but we still believe that when the 
milk is of full average richness (containing ten or fifteen per cent, of 
cream, and having a specific gravity of 1028 to 1030), the old rule of 
two-thirds water is safest. And this is certainly true of all sickly 
children within the month. It is easy to increase the proportion after- 
wards, if the child does not develop as it ought; but the stomach once 
seriously deranged and overloaded by too rich a food, a severe and 
even a lingering illness may be the penalty the child will have to 
suffer. 

When the child comes to be one or two months of age, the propor- 
tion may be increased to one-half, with care; always, however, return- 
ing to the first rule, should the child exhibit signs of gastric disturb- 
ance, or should the stools contain many whitish lumps, consisting of 
undigested casein. At the age of five or six months the proportion 
may be made two-thirds milk, and thus, gradually, the milk may be 
given pure, though we have seen many children who, even at a year of 
age, did better with a moderate dilution than with the pure fluid. 

The quantity of food to be given each day is a very important con- 
sideration, and one about which less is usually said than the matter 
deserves. In the first edition of this work, published in 1848, it was 
stated that, from various inquiries and observations, we were lead to 
believe that a healthy infant of two or three weeks old, would receive, 
from a good nurse, and digest well, about a pint of food in twenty-four 
hours^ and that by the end of the first, and in the second month, the 
quantity taken by the child increased to a pint and a half or a quart. 
Some of the data upon which these assertions were based were the fol- 
lowing: A woman, attended in her confinement by one of us, had a 
pint of milk drawn, by the nurse, daily from the breasts, in addition to 
what the child took. On asking the nurse how much she supposed the 
child — a vigorous, hearty boy — took at the same time, her reply was 
that, judging from the frequency and vigor with which he nursed, she 
supposed he took as much as was drawn from the breasts. Another 
patient lost her child at birth, and desiring to go out as a wet-nurse, 
kept up the flow of her milk by using a puppy. Six weeks after her 
confinement, a good breast-pump was given her, and she was desired 
to keep all the milk she could obtain in twenty-four hours. The quan- 
tity measured exactly a quart. 

It was also stated, in that edition, that careful inquiries were made, 
in regard to this matter, of one of the most experienced and intelligent 
monthly nurses we ever knew. She was desired to answer accurately 
the two following questions: 



336 THRUSH. 

1. How much milk do you think a healthy mother gives to her child 
daily, after the flow is fajrly established? 

2. AYhat quantity of nourishment do you give in twenty-four hours, 
to infants you are compelled to feed exclusively? 

The reply to the first question was that she had often drawn more 
than a pint from the breasts in the twenty-four hours, in addition to 
what a healthy child took, and that she had frequently taken as much 
as three pints from women who had lost their children. She supposed, 
therefore, that a hearty child would take, during the first two weeks, 
at least a pint, and much more afterwards. 

To the second question she replied, that she usually gave to hearty 
children of one, two, and three weeks old, a pint of food in twenty-four 
hours. 

It was stated in the first edition of this work, that, judging from the 
above data, a young infant ought to take at least a pint of nourishment 
in the twentj^-four hours. Our experience, since that time, has con- 
vinced us that, if anything, this estimate is rather too low than too 
high. ]S"ow w^e should say that, in the first ten days after birth, a pint 
or a little over is about the right quantity. After that period a pint 
and a half to a quart is probably the proper amount up to the second 
month. In the second and third months man}" children require a full 
quart, and some three pints ; though, after all, we must be ruled very 
much by the instinctive wants of the individual child. When fed at 
regular intervals, upon food of the proper strength, we do not think 
children often take more than they need. 

In the first month the child ought to be fed every two hours, if it 
takes the food well. After the first month, once in three hours, is 
usually the best rule. Feeding the child once in three hours, between 
six in the morning and six in the evening, and twice in the night, would 
give six meals in the twenty-four hours. If six ounces (a gill and a 
half) be given each time, the child would get thirty-six ounces, which 
is a little over a quart. As the age increases, eight ounces may be 
given every four hours, which would make a quart and a half; and we 
have met with very few children who exceed this, particularly as by 
this time the food consists of two-thirds or three-fourths milk, or even 
pure milk. It may seem needless to add that, unless the child is taking 
decidedly less than the average stated above, it ought not to be in any 
degree forced or enticed to swallow more than it takes willingly. The 
moment it has had enough, the nurse ought to cease to offer any more. 

As this matter of the quantity of artificial food necessary for the devel- 
opment of the child is a very important one, and as it is a point which 
has not been very clearly defined by most writers, we have thought it 
well to lay before our readers the following calculation of what infants 
may need, from the estimate made by Dr. Parkes as to the amount of 
food necessary for adults. 

According to that author, an adult of average size and activity will, 
under conditions of moderate exertion, take in twenty- four hours from 
2'gth to Jgth of his own weight in solid and liquid food. The relative 



QUANTITY OF FOOD NEEDED BY CHILDREN. 



337 



proportion of the so-called solid and liquid food varies greatly, but is 
usually about 40 oz. avoirdupois of the former, and 60 oz. of water. 
As, however, all the so-called solid food — bread, meat, &c. — contains a 
certain amount of water, the actual average amount of water-free food 
taken by an adult, weighing 150 lbs., is 23 oz., or j^th of the weight 
of the body; and the amount of water about 75 oz. Or, in other words, 
every pound weight of the body receives about 0.15 oz. of water-free 
food and 0.5 oz. of water in twenty-four hours. This water-free food 
is composed as follows, according to Moleschott : 



Albuminous substances, 
Fatty " 

Carbo-bvdrates, . 
Salts (of all kinds). 



oz. avoirdupois = 437.5 gr. 

4.587 

2.964 

14.257 

1.058 



22.866 



On the basis of these calculations, an infant at birth, the average 
weight being 7 lbs., would require 1.05 oz. of water-free food; and a 
child weighing 20 lbs., which is probably the average weight of healthy 
children of five to six months old, would require 3 oz. 

Assuming the total solid of cow's milk to be 10 per cent., which is 
rather less than the average as given by Becquerel and Eodier (see 
composition of healthy milk), it would require to yield an ounce of 
water-free food rather more than 10 ounces of milk. 

Thus on this supposition (l e., that the total solids of cow's milk of 
sp. gr. 1026, equal 10 per cent.) one pint imperial (20 oz.) will contain 
in round numbers, 



Casein, 


. 262 grains 


Fats, . 


. 217 " 


Lactin, 


. 341 " 


Salts, . 


. 43 " 



Total, 



very nearly 2 oz. avoirdupois of water-free food. 



According to this, therefore, the infant at birth requires little more 
than i pint imperial of unskimmed cow's milk; the child at five or six 
months about IJ pints imperial. 

It is evident that the proportion of fat and water is in great excess 
in this exclusively milk diet; but these two principles are required in 
early infancy in much larger relative amount than at a later period of 
life. It will also be seen that by diluting the above amounts of cow's 
milk with one to two parts of water, we obtain, as the proper amount 
of food for new-born infants, from a pint to a pint and a half; and for 
children about five or six months old, from 3 to 4 pints, amounts which 
correspond closely with the results obtained from examination of the 
quantity of milk secreted by nursing women. 

Some authorities recommend the regular use of lime-water, instead 
of simple water, for the purposes of dilution. We ourselves have not 

22 



338 THEUSH. 

been in the habit of using it, except when the rejection of the milk in 
bard and hirge curds, or the frequent appearance in the stools of small 
whitish lumps of undigested casein, showed a too early and too great 
coagulation of the milk in the stomach. In such cases we always direct 
lime-water to be added to each meal. As to the quantity of this alkali, 
we will state that Dr. Eustace Smith (^Wasting Diseases of Children^ 
London, 1868, p. 33), directs, during the first six weeks of life, that 
half lime-water and half milk be used. Dr. Eouth (Infant Feeding, 2d 
ed., London, p. 397) advises that from an ounce to an ounce and a half 
of lime-water be added to each pint of food. The latter is about the 
proportion we use. In many cases, however, our patients do perfectly 
well without any. 

Besides the dilution with water, sugar must always be added. Form- 
erly, the best lump white sugar was always used. Brown sugar has 
been found not to answer well. Of late, experience has shown that 
sugar of milk, which is the natural sugar found in this fluid, is prefer- 
able to cane sugar. The amount of sugar of milk to be added should 
always be specified by the physician, and not left to the hap^hazard 
judgment of the nurse or mother, as most persons use too much. A 
drachm and a half, or about a heaped teaspoonful, is the pro^^er pro- 
portion for each eight ounces of food. 

Many different and more or less complicated preparations of food 
have been recommended by different authorities. We do not think 
that any of the various feculent substances, so much vaunted and ad- 
vertised for the use of the public, are of any value in the early 
months, as compared with milk. Milk must be the basis. It is the 
really important part of the nutriment. It matters not greatly what 
be the feculent substance used, we think, if only the milk be good 
and in sufficient quantity, and the feculent material be in small propor- 
tion. To depend on amylaceous food is usually to sicken, and finally 
to starve the child. And yet we have found by experience that a small 
quantity of amylaceous material combined with the milk does render 
the food more digestible. We think that the opinion held by several 
physicians, that the particles of starch lessen the tendency of cow's 
milk to coagulate into hard large masses, by being interposed between 
the elements of the casein, may be the correct one. At all events, ex- 
perience, as stated above, has led us into the habit of using a. small 
quantity. The following preparation was published in our first edition, 
and we have employed it in a great many instances, and have found 
it the best substitute, as a rule, for the natural aliment, that we are 
acquainted with. 

It is made by dissolving a small quantity of prepared gelatin or 
Eussian isinglass in water, to which is added milk, cream, and a little 
arrowroot, or any other farinaceous substance that may be preferred. 
The mode of preparation and the proportions are as follows : A scruple 
of gelatin (or a piece two inches square of the flat cake in which it is 
sold) is soaked for a short time in cold water, and then boiled in half a 
pint of water until it dissolves, — about ten or fifteen minutes. To this 



QUANTITY OF FOOD NEEDED BY CHILDREN. 339 

is added, with constant stirring, and just at the termination of the 
boiling, the milk and arrowroot, the latter being previously mixed into 
a paste with a little cold water. After the addition of the milk and 
arrowroot, and just before the removal from the fire, the cream is poured 
in. and a moderate quantity of loaf sugar added. The proportions of 
milk, cream, and arrowroot must depend on the age and digestive power 
of the child. For a healthy infant within the month, we usually 
direct from three to four ounces of milk, half an ounce to an ounce 
of cream, and a teaspoonful of arrowroot to a half pint of water. 
For older children, the quantity of milk and cream should be gradually 
increased to a half or two-thirds milk, and from one to two ounces 
of cream. We seldom increase the quantity of gelatin or arrow- 
root. 

We have given this food to a great many children during the last 
twenty-five years, as well to those brought up entirely by hand, as those 
partly suckled, or weaned, and can truly state that they have thriven 
better upon it than upon anything else we have employed. In several 
cases it has agreed perfectly well with infants who could not, without 
vomiting, diarrhoea, and colic, take plain milk and water, cream and 
water, any kind of farinaceous food prepared with water, chicken 
water, or in fact any other food that had been tried. In the cases of 
sick children, it ought sometimes to be made even weaker for awhile 
than in the proportions first mentioned above. 

We have been pleased to find that Dr. Eouth (loc. cit., p. 315) quotes, 
with great approval, a food recommended by Dr. Merei for feeble chil- 
dren, with bowels previously deranged, which is almost exactly the 
same as the above. Dr. Merei is one of the physicians of the Clinical 
Hospital for the Diseases of Children, in Manchester, and one who 
must therefore, have had a large experience. He first makes a decoc- 
tion of arrowroot with a teaspoonful of arrowroot to threerquarters of 
a pint of water, this quantity to serve for a whole day's supply. It is 
stated b}^ Dr. Routh, that the arrowroot is not given as an aliment, but 
as a softish substance, to soothe mechanically the irritation of the in- 
testinal mucous membrane. "Langenbeck, indeed," he says, "believes 
that in such cases the granules of starch intersperse themselves between 
the particles of casein, and thus in great measure prevent the formation 
of hard, indigestible curds." The mixture Dr. Merei gives, is stated to 
consist of three or four parts of this thin decoction of arrowroot, to one 
part of new milk, slightly boiled ; and to the twenty-four hours' amount 
of food thus prepared, he adds about one or two tablespoonfuls of cream. 
Children, it is further stated, will digest well from a pint to a pint and 
a half of this mixture in twenty-four hours, according to their age. 
As they grow older, he increases the proportion of milk, but not of 
cream. 

This is so much like our own preparation, recommended twenty-five 
years ago, that we feel strengthened in our own conviction as to its 
utility, particularly as the two experiences have occurred so far apart as 



340 THRUSH. 

England and America, and to persons who have reached the result by 
experience as well as theory. 

There are other preparations, such as those of Dr. Frankland and 
Mr. Lobb, which may do well in some cases, but they are so complex, 
and require so much time, as to render them almost useless in the nur- 
sery. The one recommended by Baron Liebig, called Liebig's food, we 
have used occasionally, but have been disappointed in its action; and it, 
likewise, is so diflScult of preparation, that we doubt its coming into 
general use in the nursery, where a food, to be well and properly pre- 
pared, must be simple. 

The causes which compel us to resort to artificial food for young chil- 
dren, are, of course, very numerous. Thus, it may be impossible, after 
the death of the mother, to secure a reliable wet-nurse; or the mother's 
supply of milk may be manifestly insufficient; or again, although the 
quantity is abundant, the milk either disagrees with the child, and causes 
vomiting and diarrhoea, or does not nourish it properly. In every case, 
therefore, where we have reason to suspect that the mother's milk is 
of improper quality, we should subject it to a careful examination ; and, 
it is needless to add, that whenever a wet-nurse is chosen, a similar 
examination of her milk should invariably be made. 

According to Yernois and Becquerel, who examined the milk of 
eighty-one nursing women, the composition of a healthy woman's milk 
is as follows : 

1000 parts of milk contain — 

Water, 889.08 

Sugar, 43.64 

Casein, . , . 39 24 

Butter, 26.66 

Salts, 1.38 

For practical purposes, however, it is quite sufficient for the physician 
to determine the specific gravity, the reaction, the amount of cream, 
and the microscopic appearances of the milk. The first three of these 
points are to be ascertained in the way already directed in the exami- 
nation of cow's milk. The density of the milk should be about 1030 to 
1032. The amount of cream, as tested by the graduated galactometer, 
should be at least three per cent. In regard to the reaction, our own 
observations are not in accordance with the statements of the majority 
^of authors. Thus, according to Yogel {op. cit., p. 32), "fresh woman's 
milk is bluish-white or pure white, has a feebly sweetish taste, and alka- 
line 7'eaction." In order to determine this point, the following observa- 
tions were made on forty-three women in the Philadelphia Hospital : 

The subjects chosen were all in good health, and varied in age from 
nineteen to forty-one years. They were all suckling their own children, 
who were from nine weeks to eighteen months old, and, in three-fourths 
of the instances, in good health and well grown. In a good many cases 
the children had suffered more or less severely from diarrhoea during 
their teething. 



MICROSCOPIC EXAMINATION OF MILK. 341 

The mode of testing was as follows: A few drachms of milk were 
first expressed from the nipple and rejected ; a couple of drachms more 
were then expressed into a spoon, and tested with litmus- and turmeric- 
papers. In no instance was there the slightest alkaline reaction with 
the turmeric. In one instance onlj'- was there an acid reaction, and 
that a very faint one; while in fort3^-two of the forty-three cases, in 
nineteen of which the milk was tested twice, on successive days, the 
reaction was neutral. 

It is necessary, in thus testing tKe milk, to express it into a spoon, 
since litmus-paper is reddened when applied to the moist nipple. 

It would appear, then, from these observations, that woman's milk 
can, at least, not be regarded as unhealthy on account of having a neu- 
tral reaction. 

The microscopic examination should determine the quantity and size 
of the filt-globules, and the presence or absence of colostrum-corpuscles. 

The fat-globules, also called rnilk-globules, which are observed in healthy 
woman's milk, should not be very numerous, and should not vary in 
size more than from the 0.0012 to 0.0020 of an inch in diameter. The 
fat-globules, as present in milk, are invested with a delicate albuminous 
envelope. If the milk be allowed to stand, and the upper stratum of 
cream Avhich forms be examined, along with the ordinary fat-globules, 
there will be numerous others of much larger size. 

In addition to these fat-globules, there are also found in the milk 
during the first two or three weeks after confinement, a number of 
granule-cells, the so-called ^^ colostrum corpuscles." These bodies, which 
present the ordinary appearances of granule-cells wherever found, con- 
sist of an aggregation of minute oil-globules in an albuminous basis; 
they vary from 0.003 to 0.006 of an inch in diameter; and when exam- 
ined by transmitted light, appear opaque and dark-colored. After the 
period above mentioned (end of the second week), they should diminish 
rapidly in number, and only reappear in case the nursing woman is at- 
tacked with any acute febrile affection. If, therefore, they are found 
to persist long after the time mentioned, or if, having almost disap- 
peared, they return in numbers, the milk must be regarded as unhealthy. 

After these general remarks on the diet for hand-fed children, which 
we hope will not be thought too tedious^ having regard to the great im- 
portance of this subject, not only in thrush, but in all the diseases of 
childhood, we return to the treatment of the special disease under con- 
sideration, thrush. 

Few children, with thrush, unless the case be a very mild one, will 
take the full allowance of milk and water we have assumed to be neces- 
sary in the first weeks after birth. It is clear, however, that if the pa- 
tient be taking only half a pint or a gill a day, it cannot live long on 
so much less than the natural quantity. It ought to take, under these 
circumstances, about two or three tablespoonfuls of food every two or 
three hours, between morning and evening, and once or twice in the 
night, which would amount to from eight to ten ounces in the day; 
and this quantity ought to be given if the child can be induced, without 



342 THRUSH. 

forcing, to take so much. If the usual proportion of two parts water 
to one of milk, or if the arrowroot and gelatin preparation above rec- 
ommended, should be rejected in bard curds, or if masses of undigested 
curd be found in the stools, it is best, for a few days, to dilute with three 
or even four parts of the arrowroot solution, or to try for a short time, 
merely cream and water, one part of the former to three, four, or five, 
of the latter, returning to the mixture of cream, milk, and water, as 
soon as possible. 

In mild cases of the disease, which have been caused by some tempo- 
rarily unhealthy state of the nurse's milk, or, as we have seen it, from 
the occasional use of artificial food to eke out a diminished supply on 
the part of the nurse, after regulating the diet as directed, the use of 
the following mixture, which we have employed for many years past, 
will often prove very successful and tranquillizing: 

^. — Sodse Bicarb., ........ ^ss. 

Tr. Opii Camph., gtt. xl. 

Tr. Ehei, gtt. Ixxx. 

Syrup. Simp., f^ij. 

Aq. Menth., f^xiv. — M. 

A teaspoonful three times a day. 

This dose, continued for several days, or even weeks, will, unless the 
cause continue in force, relieve the jDain and wakefulness, lessen the 
diarrhoea, and greatly promote the comfort of the child. In connection 
with this, the mouth should be touched, once or twice a day, with a 
solution of nitrate of silver, of one grain to the ounce. 

In the grave form of the disease it is necessary, after regulating the 
diet, to employ remedies for the disordered condition of the alimentary 
canal. These should consist principally of alkalies, astringents, oj)iates, 
occasionally a dose of some laxative substance, nitrate of silver, and the 
external exployment of baths, warm cataplasms to the abdomen, and 
sometimes of revulsives. 

The alkalies usually employed are soda, lime-water, magnesia, chalk, 
and prepared crab's-eyes. Of these we prefer, in most cases, the soda, 
lime-water^ chalk, or crab's-eyes, to be given in the manner which will 
be recommended in the article on entero-colitis. Dewees recommends 
very highly the following formula: 

R- — Magne?. Alb. TJst., gr. xij. 

Tinct. Thebaic, gtt. iij. 

Sacch. Alb., q. s. 

AquseFont., f^j. — M. 

A teaspoonful to be given every two hours until the bowels are tranquil. 

He says of it that he has "long adopted it with entire success." In 
conjunction with the internal use of alkalies and astringents, we would 
recommend the practice pursued by M. Yalleix of employing opiate 
enemata and warm poultices containing laudanum, applied upon the 
abdomen. The enemata should consist of one drop of laudanum in a 



LOCAL TREATMENT. 343 

tablespoonful of starch-water for young infants, to be used morning 
and evening. Tiie poultices may be made of Indian or flaxseed meal, 
placed between two pieces of soft gauze flannel, to be secured around 
the body by a band, and renewed from time to time. 

Purgative remedies are much used in this country in all cases of intes- 
tinal disorder. \Ye believe them to be unnecessar}', and generally in- 
jurious, in thrush, except at the onset, and occasionally through the 
course of the disease, when we may suppose the bowels to contain 
accumulations of partially digested aliment, or highly irritating secre- 
tions. Under these circumstances, and only then, from half a tea- 
spoonful to a teaspoonful of castor oil, or a teaspoonful of spiced syrup 
of rhubarb containing half a drop of laudanum, may be prescribed, and 
repeated in case the same condition of things should recur. When once 
the diarrboea with green watery stools is established, we believe all cath- 
artics to be, as a rule, injurious. 

Opiates, in moderate quantities, given in combination with alkalies 
or astringents, or used by injection or externally, are of the greatest 
service at all stages of the grave form of the disease. When the diar- 
rhoea is severe and obstinate, and particularly when the stools contain 
mucus or blood, or are attended with tenesmic straining, nitrate of 
silver given internally, or used by injection, may be resorted to with 
ver\' probable benefit. The doses and modes of administration will be 
described under the heads of entero-colitis and dysentery. 

Some authors recommend the application of one or two leeches to 
the margin of the anus, or over the left iliac fossa. We think they can 
rarely be proper, and if so, only in vigorous, hearty children, and in 
cases presenting strongly marked inflammatory symptoms. When the 
symptoms indicate great exhaustion, or tend towards a state of col- 
lapse, resort must be had to stimulants, of which the best are weak 
brandy and water, or a mixture of equal parts of wine-whey and arrow- 
root water. 

Local Treatment. — The local treatment is important in all cases, 
but is of much less consequence than the general treatment, and par- 
ticularly attention to the diet and other hygienic conditions of the 
patient. Topical remedies undoubtedly have the efl^ect, however, iu 
some instances, of arresting the progress of the exudation, and hasten- 
ing the resolution of the disease of the mouth; but we have uniformly 
found, in grave cases, that no remedies applied to the mouth had any 
decided influence upon the abdominal disease, which is, after all, the 
cause of the fatal termination in the vast majority of cases. The local 
treatment ought, therefore, to be regarded as adjuvant only to the 
general management of the disorder. 

In mild cases the most suitable local treatment, the one recommended 
by Underwood, Dewees, Eberle, and MM. Trousseau and Delpech, and 
that which we have generally employed, is the occasional application 
to the mouth of borax. It may be used mixed with an equal quantity 
of honey, and applied by means of a rag or pencil; or with an equal 
quantity or two parts of finely powdered white sugar, of which a pinch 



344 AFFECTIONS OF THE TONSILS. 

is to be put upon the tongue every two or three hours; or in solution, 
in the proportion of a drachm to two ounces of water. The best mode 
probably is to mix it with honey. If this application fail to arrest the 
deposit of the exudation, we may resort to alum in powder or solution, 
or, better still, to solutions of nitrate of silver, or to careful cauteriza- 
tion with the solid nitrate. The alum may be used in the same man- 
ner as borax, or according to the following formula, recommended by 
M.Yalleix: 

R. — Aluminis, ....... gr. xv. 

Mel. RosEe, ...*.... ^ijss. 

Decoct. Hordei, ...... f5iijss. — M. 

In the use of the nitrate of silver, we should resort to a solution of five 
grains to the ounce of water. MM. Trousseau and Delpech, however, 
recommend one of thirty grains to the half ounce, or more frequently 
cauterize lightly the whole mucous surface with the solid caustic. 

Between the applications of any of the above-mentioned remedies, the 
mouth of the infant ought to be occasionally moistened and cleansed 
with some of the muciUxginous solutions, as gum-water, flaxseed tea, or 
that made from sassafras pith, slippery elm bark, or marsh-mallow 
root. 

Strict and careful attention must be constantly paid to the state of 
the skin around the anus, and upon the thighs and buttocks. Tbese 
parts ought to be well cleansed, after each evacuation of urine or stool, 
by gentle pressure, and not by rubbing, with a fine sponge dipped into 
tepid milk and water, then dried with a soft napkin in the same man- 
ner, and well anointed with simple cerate, or, what we find better than 
anything else, Goulard's cerate. These precautions ought to be still 
more carefull}- observed if erythema has already made its appearance. 



ARTICLE YI. 

AFFECTIONS OF THE TONSILS. 

1. Acute Inflammation of the Tonsils. — Tonsillitis. — This pain- 
ful affection (known also as angina or cynanche tonsillaris), occurs in 
childhood less frequently, but with the same symptoms as after the age 
of puberty. We have occasionally met with severe cases of it in chil- 
dren under the age of 5 years. 

Symptoms. — When the attack is sudden, there are marked fever, rest- 
lessness or heaviness, and complaints of severe pain on deglutition. If 
the child be old enough to answer questions, the pain will be found to 
radiate from the fauces towards the ear, and to be increased by opening 
the mouth. Painful enlargement of one or both tonsiV glands will be 
found by pressing the finger below the angle of the lower jaw. On ex- 



COURSE AND DURATION — DIAGNOSIS — TREATMENT. 345 

amining. the fauces, there is marked redness of the half arches and pos- 
terior border of the soft palate : the affected tonsil projects from its bed 
as a rounded, deep-red bod}', which ma}' extend even beyond the median 
line ; and if, as less frequently happens, both tonsils are severely inflamed 
at the same time, they may even meet and entirely occlude the isthmus 
of the fauces. The surface of the gland often presents small 3'ellowish 
points which closely resemble patches of ftilse membrane, although 
careful inspection will show that they are beneath the mucous mem- 
brane, and are really onlj- the distended follicles of the gland. Deglu- 
tition is so painful, especially for, liquids such as milk or water, that 
the little patients will at times utterly refuse to swallow. 

Course and Duration. — The disease lasts from 3 to 7 days, and ter- 
minates in different ways. It very rarely proves fatal, and only 
does so by obstructing breathing, and at the same time so seriously in- 
terfering with nutrition that the child's strength fails. In most cases 
the result is fixvorable, and the termination is either by suppuration or 
gradual resolution of the enlarged gland. When suppuration occurs, 
the sj-mptoms have gone on becoming more and more aggravated until 
they reach their height, and the case seems attended with great dan- 
ger, when suddenly, after an effort at vomiting, or spontaneously, the 
tonsillar abscess bursts, a gush of pus occurs from the mouth, and 
prompt relief is afforded. Occasionally the occurrence of suppuration 
is marked by a chill, or some decided change in the febrile movement. 

More frequently in children, however, the tonsil does not suppurate 
but gradually" becomes smaller; the redness subsides, and the distended 
follicles disappear. There is a strong tendency, especially after this 
latter mode of termination, for the tonsil to pass into a state of mod- 
erate chronic enlargement. 

Diagnosis. — The conditions with which acute tonsillitis in children 
is most apt to be confounded, are diphtheria and scarlatinous angina. 

From diphtheria it may be told by the more acute and sthenic char- 
acter of the symptoms ; by the absence of enlargement of any but the 
tonsil glands, and by the local appearances, particularly the absence of 
pseudo-membranous exudation. 

From the angina of scarlatina it may be distinguished by the less 
frequent pulse and lower temperature, but chiefly by the absence of 
eruption, so that in some cases the diagnosis cannot be positively deter- 
mined until the time at which the eruption of scarlatina makes its 
appearance has passed. 

Treatment. — So long as the child is able to swallow, quinia may be 
given in full doses, to diminish the fever, and perhaps diminish the lia- 
bility to suppuration- It may be given combined as follows : 

R. — Quinise Sulph., gr, xviij. 

Tr. Ferri Chloridi, . . ... . gtt. xlviij. 

Potassse Chloratis, ..... gr. xxx. 

Syr. Zingiberis, f^j. 

Aquae, f^ij. 

Dose : Ft. sol. 2 teaspoonfuls 4 times a day, for a child 5 to 7 years old. 



346 AFFECTIOKS OF THE TONSILS. 

If, however, the inflammation be very acute, suppuration will occur 
in all probability, despite our efforts. 

It is almost impossible to make any applications to the throat. That 
which is most readily effected, and affords as much relief as any other, 
is the inhalation of steam or vaporized warm lime-water. Warm, 
slightl}' sedative embrocations may also be applied to the neck. It is 
doubtful whether poultices, or any such applications, hasten suppura- 
tion sufiSciently to make up for the annoyance they cause the child. 
Even if the occurrence of suppuration be suspected, it is usually im- 
possible to obtain so full a view of the parts as to enable an incision to 
be made to evacuate the pus. As, however, the abscess will discharge 
spontaneously' in nearly all cases, it is only when the symptoms of ob- 
struction of the throat are very urgent, that it is desirable to insist 
upon such an examination. 

The treatment for the chronic enlargement which sometimes remains 
after an acute tonsillitis, will be considered in the next section. 

2. Chronic Enlargement (Hypertrophy) of the Tonsils. — 
Causes. — The tonsils are in young children much more subject to this 
affection than to acute inflammation. The enlargement may begin 
during the first year of life, but usually does not become sufficient to 
attract attention until the second or third je^r. Most frequently it has 
no connection whatever with previous acute inflammation of the part, 
but is chronic and indolent from the beginning. It is often observed 
that several children of the same family will suffer from this condition, 
and it is in fact associated in many cases with rickets or with scrofula. 
We have, however, observed marked and enduring enlargement in 
children of apparently sound constitution. According to West, the 
irritation of the latter period of first dentition may be the exciting 
cause in some of these cases. 

We have already alluded to the fact that occasionally, especially in 
somewhat older children, it has been an acute attack of tonsillitis — 
either simple or diphtheritic — which has induced the state of chronic 
enlargement. 

Anatomical Appearances. — Both tonsils usually share in the en- 
largement, though not always to an equal degree. They project into 
the fauces from either side, forming pale red tumors of rounded form, 
with a surface that may either be smooth and glistening, or rough and 
irregular from the rupture of numerous distended follicles. They im- 
part a sense of elastic firmness to the finger when pressed. The exact 
anatomical condition is in part an enlargement of the follicles of the 
gland, associated with thickening of the fibro-cellular stroma. The 
term hypertrophy, commonly applied to this condition, must therefore 
be regarded as indicating merely the increase in size of the gland. 

Symptoms. — There can be no doubt but that many symptoms have 
been attributed to the influence of enlarged tonsils which are in reality 
dependent upon entirely different causes. 

The results which are constantl}^ observed are loud snoring during 
sleep, and snuffling, thick voice. There is also often a tendency to 



PROGNOSIS — TREATMENT. 847 

acute catarrhal attacks, during which the enlargement of the tonsils 
increases, and the interference with the breathing and voice is much 
increased. Indeed, in some, unusually severe cases the respiration is 
constantly labored, and the child is annoyed by a frequent dry hacking 
cough. The pressure of the enlarged glands upon the mouths of the 
Eustachian tubes may ])roduce tinnitus and hardness of hearing. The 
most serious results which are, by many authors, attributed to enlarge- 
ment of the tonsils are alterations in the nose and upper jaw, and the 
production of the chicken-breast deformity of the thorax. In conse- 
quence of the obstruction of the nasal passages caused by the upward 
pressure of the soft palate, the form of the anterior nares may be some- 
what altered and contracted, but we are rather inclined to refer the 
small size of the features and the ill-developed upper jaw to the rick- 
ety cachexia which is so frequent a cause of enlargement of the tonsils. 
So, too, the narrowing of the isthmus of the fauces must tend to make 
inspiration difficult, and thus to prevent full expansion of the chest, 
but we can hardly imagine that such obstruction could produce marked 
chicken-breasted deformity of the thorax, if it were not for the fact that 
in such patients there is usually a high degree of rickets coexisting. 
It must be borne in mind that precisely this deformity of the thorax is 
frequently met Avith in cases of rickets where there is no enlargement 
of the tonsils. The condition of these glands and the changes in the 
jaws and chest-walls must then, we think, be regarded as results of a 
common cause. So, too, it is probable that the sudden suffocative at- 
tacks which have been described as occasionallj' attending chronic en- 
largement of the tonsils have been spells of laryngismus stridulus, de- 
jDendent upon rachitic disease of the bones of the skull. 

Prognosis. — It will be readily seen, therefore, that although this 
condition of the tonsils is obstinate, and yields slowly, if at all, to treat- 
ment, it is rarely of itself followed by any serious consequences. In 
very many cases it gradually subsides after the patient reaches puberty, 
w^hile in others treatment is successful in reducing the enlargement. 
We have, however, known it to persist most obstinately for many 
years, even after partial ablation and prolonged treatment. 

Treatment. — The frequent association of enlargement of the tonsils 
with a rachitic or strumous diathesis must be borne in mind, and if 
there is any evidence of the existence of such a constitutional taint, the 
appropriate treatment must be adopted. Even where no decided evi- 
dence can be found, it seems desirable to administer such alterative 
tonics as the iodide of iron, or the compound syrup of the phosphates 
of iron and alkalies. The prolonged use of cod-liver oil, with iron and 
arsenic, has also proved of service. 

Counter-irritation by the daily application of dilute tincture of iodine, 
or compound iodine ointment, behind and below the angle of the jaw, 
may be used, and sometimes appears to favor the reduction of the 
swelling. 

Local applications to the enlarged glands are of much service in some 



348 SIMPLE PHARYNGITIS. 

cases, but to do good must be steadily persisted in, in conjunction with 
proper internal remedies. Those which have on the whole appeared 
most useful to us have been Lugol's solution of iodine diluted with 
two to four parts of water, and nitrate of silver in the form of rather 
strong solution, as gr. x to the fluidounce. 

We have also found it of niaterial service in hastening the reduction 
of the enlargement to whiten the surface of the tonsils once in three or 
four days by a light application of solid lunar caustic. 

Careful attention to diet, and particularly to the proper and sufficient 
clothing of the child must be insisted on, so as to avoid, as far as pos- 
sible, the repeated acute attacks of slight tonsillitis which are apt to 
occur. Under the persistent employment of the general and local 
means above recommended, we have usually found that the hypertro- 
phy of the tonsils has diminished towards the age of puberty. In some 
instances, however, we must confess that all forms of treatment, gen- 
eral as well as local, have proved unavailing. We must then resort to 
excision of the enlarged glands, if the symptoms caused by their pres- 
ence are sufficient!}" urgent to render it advisable. 

The excision of the tonsil (or rather of the prominent portion of it, 
for the entire gland rarely needs removal) is an operation attended, in 
skilful hands, with little difficult}' and no danger. It may be readily 
performed with a Fahnestock's or Physick's tonsillotome, or, as many 
operators prefer, by raising the gland from its bed with a special kind 
of forceps, and then slicing it off with a bistoury. 

The symptoms which would lead us to advise the early removal of 
the tonsils are frequent irritative cough, much interference with hear- 
ing or with the tones of the voice, or coexisting rachitic deformity of 
the chest. 



AETICLE VII. 

SIMPLE OR ERYTHEMATOUS PHARYNGITIS. 

Definition; Frequency. — Simple pharyngitis consists of an erythem- 
atous inflammation of the pharynx, tonsils, and soft palate, unaccom- 
panied by ulceration, deposit of false membrane, or gangrene. It is 
very frequent both as an idiopathic and secondary disease. We con- 
stantly meet with it in children of all ages during the cool months of 
the year. 

Causes. — It may occur at all ages, and is equally common in the 
two sexes. It is more frequently a secondary than an idiopathic affec- 
tion. The diseases in the course of which it is most apt to occur are 
scarlet fever and measles, and next, pneumonia and bronchitis. It is 
often an accompaniment of simple laryngitis. The idiopathic form is 



SYMPTOMS. 349 

most common in this city in the late winter and early spring months. 
It is said to prevail sometimes in an epidemic form. 

The exciting causes of the disease are not always easily detected. In 
most instances, however, we believe that exposure to cold is the cause 
of the attack. 

Anatomical Lesions. — In mild cases the alterations of texture ob- 
served during life, and in a few instances after death, the patient having 
died of some other disease, consist of greater or less redness, swelling, 
softening, and a rough or granular and sometimes oedematous condi- 
tion of the mucous membrane covering the soft palate, tonsils, and 
pharynx. The uvula and tonsils are generally tumefied, and the crypts 
of the latter filled with mucous or purulent fluid of a yellowish color. 
In one very severe case which proved fatal, MM. Eilliet and Earth ez 
found the tonsils very red, soft, only slightly swelled, and infiltrated 
with pus; the pharj'nx was covered with a thick layer of bloody mu- 
cus; the mucous membrane of the throat was of a dark red color, 
thickened, and granular, but not softened. The submaxillary glands 
were of a grayish color, enlarged and soft. 

Symptoms. — Simple pharyngitis of moderate severity begins with 
restlessness, irritability, fever, slight cough, and in some instances, pain 
in the throat, which is complained of by older children, and betrayed 
in those who are very young by the refusal to nurse or take food, be- 
cause of the difficulty of swallowing. The face is generally flushed, 
sometimes very deeply so. Young children are often drowsy, but from 
irritability and fever refuse to sleep except on the lap. The fever is 
marked by acceleration of the pulse, which rises to 100, 110, or more 
in children over five years of age, and to 120, 130, or 140 in those under 
that age, and by unusual warmth or even heat of the skin. At the 
same time the respiration is generally more frequent than natural, but 
almost always regular; in cases attended with high fever, we„ have 
counted the breathing at 42 and 50. Auscultation reveals pure vesicular 
murmur or slight sibilant rhonchus. The voice is clear, or, in rather 
severer cases, obscured and nasal, and in some instances, speaking is 
painful and difficult. Cough is a frequent symptom. It was present in 
20 of 25 cases observed by ourselves. In 6 of these it was harsh and 
croupal, so that the children seemed threatened with croup. The 
croupal sound seldom lasted over one night, after which the cough was 
merely hoarse, and gradually became loose towards the termination of 
the attack. In the remaining cases it was rare and dry in the begin- 
ning, and more frequent and looser as the disease progressed. Fain is 
a frequent, but far from constant symptom at the outset of the disease. 
It generally exists during deglutition. When present it is shown in 
infants, as stated, by their refusing the breast, or nursing only at long- 
intervals, and with difficulty; while in older children it is complained 
of. It is not, however, a constant symptom, as we have often seen 
children of one, two, and three years old, with severe angina produc- 
tive of violent fever, who swallowed fluids and soft solids vvithout a 
sign of pain. Of 22 cases in which the state of this symptom was par- 



350 SIMPLE PHARYNGITIS. 

ticularly noticed by ourselves, it was present only in 7. Throughout 
the acute period of the disease there is generally considerable thirst ; 
the appetite is diminished or entirely suppressed ; the stools are usually 
natural, or there is slight constipation. 

The throat should always be examined when there is the least reason 
to suspect that an attack of sickness depends upon inflammation of 
that part, and whenever a child has been seized suddenly with fever, 
particularly in cold weather, and there is nothing more evident by which 
to explain the illness. To examine this part well, the tongue must be 
strongly depressed with the handle of a spoon, which should be carried 
back to the base of the tongue. This may be done in the youngest 
infant. 

The appearances presented by the throat are as follows : The soft 
palate, uvula, tonsils, and generally the pharj^nx also, are more or less 
reddened and swelled, and the mucous membrane commonly looks rough 
and granular. The fauces are often filled with frothy mucus, and in 
severe cases coated all over with mucous or purulent secretions, which 
sometimes line the inflamed surfaces in such a way as to resemble false 
membranes. They are to be distinguished only by careful examination, 
and by removing a small portion on a pencil or sponge-mop, in order 
to ascertain their real nature. We have seen the mild form of inflam- 
mation in a child ten days old, in one eight weeks, another three months, 
and a fourth nine months old. 

Dr. Wertheimer (Jour, fur Kinderkrankheiten, Band xxxii) calls at- 
tention to a variety of angina, which he calls oedematous, and which is 
specially characterized by serous infiltration of the submucous tissue 
of the pharynx, the mucous membrane itself being pale and smooth, 
and soft and sticky to the touch. 

The submaxilUuy glands and neighboring cellular tissue are sometimes 
swollen, in consequence of the extension of the inflammation to them. 
This is often evident to the eye, but it is more correctly judged of b}^ 
the touch. At the same time the glands are usually somewhat painful 
to the touch. The amount of swelling is slight in very mild cases, or 
there may be none at all. In severer cases it is much more considerable. 

The breathis said to be often fetid. We have not met with this char- 
acter in the simple disease. Expectoration is rarely present. We have 
never noticed it under six years of age. Slight nervous symptoms occur 
in nearly all the cases, consisting, as already stated, of restlessness and 
irritability in mild attacks, and of insomnia or drowsiness, with start- 
ing and twitching, in those which are more severe. 

The fever generally occurs at first only in the after-part of the day 
and during the night, often becoming intense at that time, with rest- 
lessness and starting, and subsiding or disappearing entirely towards 
morning, to recur again the next afternoon or evening. Children not 
unfrequently play about all the early part of the day, and are attacked 
with the symptoms just mentioned as night comes on. The disease 
generally pursues this course for three or four days, and then passes 



SYMPTOMS OF THE GRAVE FORM — DIAGNOSIS. 351 

awav entirely or, if it lasts beyond that time, the fever becomes con- 
tinued, and the attack runs on for seven, eight, or ten days. 

In grave cases of simple angina, the disease begins with vomiting, fever, 
and severe nervous symptoms, in the shape of excessive restlessness, or 
somnolence, and occasionally convulsions. The fever is violent, the 
pulse being very frequent and full; and the skin hot and flushed. The 
intense heat and flushing of the skin, which in sanguine children some- 
times afi'ects the greater part of the surface of the body, together with 
the activity of the circulation, not unfrequently make the onset of the 
disease resemble very closely that of scarlet fever. Four cases of this 
kind that have come under our notice presented severe nervous symp- 
toms at the invasion. In a girl between two and three years old, they 
consisted of wildness and ecstatic expression of the face, and trembling 
uncertain movements of the limbs, which would probably have termi- 
nated in convulsions, but for the timely interposition of a w^arm bath. 
In the three others, general convulsions occurred. Two of the subjects 
in which convulsions took place were between five and six years old, 
and one between three and four. In two the convulsions occurred at 
the onset, and in a third on the second day. The convulsive move- 
ments lasted from ten to twenty minutes, and were followed by somno- 
lence for a few hours in two, and by stupor for a day in the third. It 
should be stated, however, that two of these subjects were predisposed 
by constitution and temperament to spasmodic attacks, as one had had 
a fit previously from a similar cause, and the other two from difficult 
dentition. The third had never suffered from any symptoms of the 
kind, and did not appear predisposed to them. 

The tongue is generally dry and coated with a thick whitish fur in 
grave cases; the respiration is quick, loud, and nasal; and the voice gut- 
tural or nasal, and difficult. There is usually extreme thirst, and not 
unfrequently delirium. The throat is commonly violentlj^ inflamed, of 
a deep-red color, and coated over with mucous or purulent secretions. 
The submaxillary regions are often swelled, and the deglutition some- 
times, though not always, difficult. When the disease proves fatal, the 
different symptoms soon reach their height, and death may occur in 
two or three days. We have never, however, known simple pharyn- 
gitis to terminate fatally. The duration of the grave cases is variable. 
In the four that we have noted, it was between three and eight days. 

Secondary pharyngitis, which, as has been stated, is a very frequent 
disease, will be treated of in the articles on the various diseases in the 
course of which it occurs. 

Diagnosis. — The diagnosis of simple pharyngitis is not always with- 
out difficulty, as there are no local symptoms in two-thirds of the cases 
at the invasion, nor in some instances at any period of the attack. The 
physician and attendants, therefore, are often deceived as to the real 
cause of the violent fever which has so suddenly made its appearance, 
and are disposed to refer it to any but the true one. 

It has happened to us several times in cases of children attacked with 
simple angina, to suspect pneumonia from the sudden occurrence of 



352 SIMPLE PHARYNGITIS. 

fever, rapid respiration, slight, dry cough, and the absence of pain in 
the throat, difficulty of deghitition, or other symptoms, to call our at- 
tention to the real seat of disease. The diagnosis is to be corrected 
only hy the absence of the physical signs of pneumonia, and the conse- 
quent necessity of finding some other cause of the sickness. Angina 
may be mistaken also for indigestion, which is one of the most frequent 
causes of sudden fever in childhood, and is accompanied, like severe 
angina, by vomiting. The distinction between the two is to be made 
by careful inquiry as to the. history of the attack, by examination of 
the matters ejected from the stomach, and by inspection of the throat. 
Severe cases, particularly when ushered in by convulsions, may be mis- 
taken for disorder of the nervous system dependent upon dentition. The 
only method of ascertaining the truth is again the inspection of the 
throat. Cases of this kind might also be mistaken for the beginning 
of scarlet fever. Time only, and the development or absence of the 
symptoms peculiar to the latter disease, could enable us to determine 
the diagnosis. 

The diagnosis between simple and pseudo-membranous pharyngitis 
will be given under the head of diphtheria. 

Prognosis. — Simple pharyngitis of moderate severity is very rarelj', 
if ever, a fatal disease. Severe or grave erythematous pharyngitis, on 
the contrary, is often a dangerous malady. The four cases that have 
come under our care, however, all recovered. The unfavorable symp- 
toms in such cases are : very violent fever, greatly altered physiog- 
nomy, difficult respiration, choked and guttural voice, excessive jacti- 
tation, delirium, convulsions, and coma. 

Treatment. — Mild cases of simple angina need but little treatment. 
The child ought to be confined to a warm room in all cases, and kept 
in bed, or on the lap, if it have fever. The diet must be restricted to 
milk preparations and bread, so long as the fever continues. The ther- 
apeutical part of the treatment may consist in the use of some mild 
evacuant, as one or two teaspoonfuls of castor oil, half a teaspoonful or 
a teaspoonful of magnesia, a small quantit}' of syrup of rhubarb, or what 
is all-sufficient in many cases, a simple enema. At the same time we 
may give, if the frequency of pulse, heat of skin, and restlessness be 
considerable, a few doses of spirit of nitrous ether, or spiritus Minde- 
reri, alone, or combined with from one to four drops of antimonial wine, 
according to the age. A warm bath, if the child is not afraid of it, is 
an admirable remedy when there is much excitement of the circulation; 
or a foot-bath, containing salt or mustard, may be used. Frictions over 
the throat and neck are often very advantageous; they may be made 
with hartshorn and sweet oil, with or without the addition of lauda- 
num, or a sniall quantity of spirit of turpentine may be applied upon 
the skin, so as to produce slight counter-irritation. When there is much 
pain and difficulty of deglutition, the case is best treated by the use of 
nitrate of silver in solution (5 or 10 grains to the ounce)^ or of pow- 
dered alum, applied by means of a large throat-brush. 

In the severe form of the disease the treatment must be much more 



TREATMENT. 353 

active than in mild cases. When the fever is very high, and threaten- 
ino; nervous symptoms are present, the most speedy means of control- 
lino- them is a warm bath, continued for fifteen or twenty minutes. If 
the etfects of this should be slight or transitory, one or two leeches may 
be applied behind the angles of the jaw, unless the fright and conse- 
quent resistance on the part of the child are so great as to render their 
application objectionable. Some evacuant dose should be given early 
in the attack; it may consist of castor oil, magnesia, epsom salts dis- 
solved in lemonade, fluid extract of senna, or infusion of senna and 
manna. The quantit}' must be sufficient to produce several copious 
stools, and should it f\iil to operate in three or four hours, and the fever 
continue, it is alwa3's well to assist it by means of a purgative enema. 
Two hours after the exhibition of the cathartic, it will be proper to 
resort to small doses of sulphuret of antimony with Dover's powder, 
repeated every hour and a half or two hours, in the manner recom- 
mended in the article on pneumonia. If the secretions into the fauces 
be very abundant and tenacious, so as to impede respiration, the best 
means of getting rid of them is b}^ an emetic of ipecacuanha or alum. 
If they collect again, the throat ought to be cleansed from time to time 
with a small sponge-mop. The inflamed surfaces should be touched 
two or three times a day with a solution of nitrate of silver (from five 
to ten grains to the ounce). The late Dr. C. D. Meigs was in the habit 
of employing with much benefit, in the severe angina of children, 
whether idiopathic or secondary, a wash made according to the follow- 
ing formula : 

B;. — Cupri Sulphat., 

Quiniffi Sulphat., aa, . . . . . . . gr. vj. 

Aquae Destillatse, fjj. — M. 

This is applied in the same wa}^ as the lunar caustic solution, and we 
have frequently seen it produce most excellent efl'ects. 

The four grave cases observed by ourselves recovered under very 
simple treatment. This consisted in the use of the warm bath, of 
doses of castor oil to move the bowels freely on the first day, and of 
syrup of rhubarb or enemata afterwards to keep them soluble ; of doses 
of antimonial wine and nitre every two hours in such quantitj^ as to 
avoid sickness; of mustard foot-baths; stimulating frictions to the 
outside of the throat; applications of lunar caustic solution to the 
throat internally, three or four times a day; and of rigid diet. In one 
case the warm bath was used three times in a single day, because of 
the extreme restlessness and heat of the skin, and was productive each 
time of much benefit. 



23 



354 RETRO-PHARYNGEAL ABSCESS. 

AETICLE VIII. 

RETRO-PHARYNGEAL ABSCESS. 

This name is applied to collections of pus formed in the cellular 
tissue between the posterior wall of the pharj^nx and the vertebral 
column. More frequently the abscess is seated quite high up on the 
level of the glottis, though cases are recorded where it occupied a lower 
position behind the oesophagus. 

Causes. — Eetro-pharyngeal abscess occurs idiopathically, or as a 
sequel to some of the specific fevers, or, more frequently, in connection 
with caries of the cervical vertebra. In one of our own cases, it fol- 
lowed directly upon a long sleigh-ride, and was due evidently to the 
severe chilling of the body. Although it cannot be regarded as a dis- 
ease peculiar to childhood, it is far more frequent in the first ten years 
of life than during any subsequent decade. 

Symptoms. — The early symptoms are irregular and not characteristic. 
In cases where the abscess is connected with caries of the cervical ver- 
tebrae, the symptoms of this latter condition have preceded. In all cases, 
however, the first indications which lead to a suspicion of the existence 
of a post-pharyngeal abscess are gradually increasing difficult}^ of swal- 
lowing and of respiration, which is attended with a loud, stertorous 
sound, unlike the stridulous breathing of croup. There is also marked 
stiffness of the neck, and the head is rigidly retracted. Any effort to 
bend the head forward is followed by urgent increase of the dyspnoea, 
and the same result has been noticed to follow when the recumbent 
position was assumed. There is an appearance of fulness on one or 
both sides of the neck behind the angle of the lower jaw. Of course 
the child presents a high degree of restlessness and distress, which in- 
creases until the interference with breathing and swallowing may prove 
fatal from combined exhaustion and asphyxia. In the presence of such 
symptoms as the above, a careful examination of the phar3'nx,both by 
direct inspection, if possible, and by the finger, should immediately be 
made. The mouth is usually filled with mucus, but the swelling of the 
posterior wall of the pharynx may frequently be seen projecting for- 
ward so as to constrict the pharyngeal space, and obstruct more or less 
the opening of the glottis. The finger, if carried back over the root of 
the tongue, comes in contact with a rounded swelling, which is in the 
early stages firm and somewhat elastic, and later becomes fluctuating. 
When the abscess is fully formed, the most prominent point may ap- 
pear 3^ellowish. Occasionally in the course of caries of the cervical ver- 
tebrae, perforation of the posterior wall of the pharynx occurs without 
being preceded by any such severe symptoms as have just been described 
as due to post-pharj^ngeal abscess. We have thus known the exj^ecto- 
ration of purulent matter with small fragments of carious bone, to occur 



DIAGNOSIS — PROGNOSIS TREATMENT. 355 

in such cases without any previous symptoms of marked obsti'uction 
in swallowing or breathing. 

Diagnosis. — The recognition of this affection is often difficult, and it 
is only bj' bearing in mind the possibility of its occurrence, and making 
careful examination with the finger, that we can avoid overlooking its 
existence, in cases where the symptoms are not clearly pronounced. In 
all cases, therefore, where difficulty in swallowing is superadded to 
dj'spncea, such an examination should be made. The affection with 
which it is most likely to be confounded is membranous croup, but the 
absence of the peculiar croupy cough and stridulous breathing, and the 
existence of dysphagia, retraction of the head, with immobility of the 
neck, fulness at the angle of the lower jaw, and, finally, the detection 
of the swelling at the back part of the throat, will render the diagnosis 
easy. 

Prognosis. — The termination is always doubtful. When, however, 
the existence of the abscess is early recognized, and it is promptly 
evacuated so soon as fully formed, recovery frequently ensues. Even 
when connected with caries of the vertebrae, the prognosis, although 
of course unfavorable from the nature of the primary disease, is not 
necessarily fatal. In the case already referred to as having followed 
directly upon long exposure to severe cold, the child was very ill, with all 
the characteristic symptoms of this affection, for a week, after which 
the abscess burst spontaneously, and the child recovered. 

Treatment. — The approach of a post-pharyngeal abscess can rarely 
be detected so early as to enable any preventive treatment to be adopted 
with success. Indeed, but little could be expected from the use of mild 
counter-irritants, or absorbent applications to the throat. In older chil- 
dren, if recognized before suppuration has occurred, some benefit might 
be derived from the use of one or two leeches to the angles of the jaw, 
or of a blister to the back of the neck. The use of small pieces of ice 
held in the mouth will also be found to afford relief. The main indica- 
tion, however, is to watch for the occurrence of suppuration, and then 
to make as early an incision as possible. When the seat of the abscess 
is high up this may be done by an ordinarj^ sharp-pointed bistoury, 
whose blade is guarded up to near the point by being wrapped with 
sticking-plaster. When the abscess is lower down it can sometimes be 
more safely reached and evacuated by a trocar and canula. As the 
opening should be small, there is danger of its closing with a re-accu- 
mulation of pus; and it is therefore advisable, as recommended by 
West, to press with the finger upon the sac of the abscess occasionally 
for a day or two. In cases dependent upon caries of the vertebrae, it is 
better to postpone opening the abscess until urgent symptoms are pro- 
duced by it. Here also it is necessary to employ the other means of 
treatment suitable for that condition, and especially the use of some 
mechanical contrivance by which the w^eight of the head can be sup- 
ported, and thus relief be afforded to the cervical spine. During the 
course of the disease every effort must be made to sustain the strength 
of the patient. If the interference with swallowing be extreme, nutri- 



356 INDIGESTION. 

tious enemata may be used until the abscess can be evacuated. In 
addition, we must use opiates in sufficient amount to quiet the excessive 
pain and restlessness. 



CHAPTER 11. 

DISEASES OF THE STOMACH AND INTESTINES. 
GENERAL REMARKS. 

In our division of these diseases, we shall treat first of Indigestion, 
using this term to signify morbid conditions of the digestive function, 
which we suppose to be the result of functional disorder, or of mild, 
acute or chronic catarrh of the stomach. Under the title of Gastritis 
we shall describe the much more rare and dangerous form of disease, 
in which there is acute inflammation of one or more of the coats of the 
stomach, and which is seldom met with except as the consequence of 
the application of some direct irritant to the organ. 

We shall then describe Simple Diarrhoea, in which we suppose the in- 
testinal disorder to be either merely functional, or one of slight catar- 
rhal inflammation of the mucous membrane. Next, under the title of 
Entero-colitis or Inflammatory Diarrhoea, we shall treat of that form of 
diarrhoea which is now by many writers styled acute or chronic catarrh 
of the intestinal mucous membrane, and the chronic forms of which we 
believe to be of the same nature as the disease designated by most of 
the observers whose experience was gathered in the vast field of the 
late war, chronic diarrhoea. We shall pass on then to Cholera Infantum, 
limiting this term to cases in which the disease is of a true choleraic 
type; and, lastly, we shall consider Dysentery. We have also added 
separate articles on the diseases of the Caecum and Appendix Yermi- 
formis, and upon Intussusception. 



SECTION I. 

FUNCTIONAL DISEASES OR MILD CATARRH OF THE STOMACH AND 

INTESTINES. 

ARTICLE I. 

INDIGESTION. 

Definition ; Frequency ; Forms. — By the term indigestion, we mean 
that condition of the stomach in which its function of digestion is dis- 



CAUSES. 357 

turbed or suspended, iDdependent of inflammation or other disease of 
the organ, appreciable by our senses; or in which there has been found 
after death, in the few opportunities that have been met with to make 
such an investigation, the lesions which are now usually designated as 
mild gastric catarrh. The only anatomical alterations found in such 
cases, are reddening of the mucous membrane in spots by a fine injec- 
tion, relaxation of its tissue, and the presence of a layer of tough mu- 
cus. It is a very frequent affection during the whole period of child- 
hood, and is one of great .importance on this account, and from the fact 
of its laying the constitution open, by the debility and cachexia which 
it produces, to various secondary affections. In our description of the 
disease, we shall distinguish between the forms which occur during in- 
fancy, and after the completion of the first dentition. 

Causes. — The principal causes of indigestion in infants are an un- 
healthy state of the milk of the nurse, the use of artificial diet, and 
lastly, an impaired condition of the digestive function, which disables 
the stomach from digesting even t"he most healthful aliment. 

The milk of the nurse may be too old for the child, for it has been 
found that a breast several months old, sometimes, though not always, 
disagrees with a young infant, in consequence, no doubt, of the milk 
being thicker and richer at that time than immediately after parturi- 
tion. The breast-glands may continue to secrete colostrum for weeks 
or even months after parturition, and when this is the case the child is 
almost sure to suffer from indigestion and diarrhoea. The milk ma}^ be 
unwholesome because the nurse is in bad health, or because her diet is 
not properly regulated. That the diet of the nurse affects her milk, 
we have no doubt, though it has been denied by some persons. 

We have known several children to suffer from indigestion, attended 
with vomiting, acid secretions, colic, and diarrhoea, in consequence of 
the nurse having indulged in a very rich diet, and particularly in vege- 
tables and fruits. We do not mean to assert that all nursino^-wornen 
should abstain from fruits, or even live on a very simple diet, for we 
have known some who could make use of the richest food, and eat 
abundantly of all kinds of vegetables and fruits, without the least in- 
jury to the child. But there are others who cannot do so without occa- 
sioning indigestion in their infants, because, probably, their children 
are unusually susceptible to the action of the materials absorbed from 
that kind of food. Again, it is clearly proved by recorded cases and by 
the opinions of various authorities, that the milk of the nurse is affected 
by her moral condition. Children have been known to suffer greatly, 
and even to die, from taking the milk of a nurse who had just before 
undergone a fit of violent anger. The depressing moral emotions, as 
anxiety, grief, fear, and despair, are well known to affect the milk 
secretion in such a way as sometimes to occasion indigestion. 

The use of artificial diet for young infants, or as the expression is, 
" bringing up on hand or the bottle," is, we believe, by far the most 
frequent cause of indigestion during infancy. Yery many children with 
whom this is attempted, die of indigestions, chronic diarrhoeas, gastritis, 



358 INDIGESTION. 

entero-colitis, cholera infantum, and thrush. Yery few escape frequent 
attacks of one or other of the diseases just named. Much depends, no 
doubt, on the selection and preparation of the food. It may be stated 
as a well-established fact, that a diet consisting wholly or in a great 
part of farinaceous substances, very rarely fails to disagree with the 
child, and to produce indigestion and other disorders of the digestive 
system, which often prove fatal ; while one in which cow's or goat's 
milk enters as the principal ingredient, though inferior to the natural 
aliment, and often productive of indigestion, is far less injurious than 
the one before spoken of 

A third cause of indigestion was stated to be the absence or loss of 
the digestive power of the stomach, independent of the nature of the 
food. This is a condition similar to the dyspepsia of the adult. It may 
be congenital or may result from causes brought into action after birth. 
It often remains as a consequence of previous indigestions from im- 
proper or excessive feeding. It exists during the invasion, course, and 
convalescence of various diseases. Dentition frequently diminishes or 
impairs the tone of the digestive function, so that the child is often un- 
able, during that process, to digest aliment which had agreed with it 
perfectl}" well at other times. 

The causes of indigestion after the completion of the first dentition 
are congenital feebleness of the digestive function ; a certain want of 
power of that function, which remains often for years in children reared 
upon artificial diet, and in those who have been debilitated by frequent 
attacks of disease of any kind; the habitual use of improper diet; the 
eating of crude, indigestible food; the process of the second dentition ; 
the want of due exercise in the open air; residence in large cities; and 
undue exercise of the mental faculties in the conduct of the education 
of the child. 

Symptoms. — We shall describe first the symptoms of indigestion as it 
occurs during infancy, and secondl}^ as it occurs during childhood, or 
after the completion of the first dentition. 

Indigestion during infancy may be advantageously considered undor> 
two heads: as occasional or accidental, and as habitual. By the former 
we mean that which occurs in a healthy infant from a transient cause, 
such as repletion or a momentarily unhealthy state of the nurse's milk 
from some imprudence on her part as to diet, from some moral cause, 
or from sickness; and that which depends upon the passing influence 
of dentition. By habitual indigestion, we mean the form of the afi'ec- 
tion which is long continued in consequence of a persistence of the 
cause. 

The symptoms of occasional or accidental indigestion in infants are: 
paleness and contraction of the face; restlessness and peevishness; 
moaning and crying, or in some cases, screaming; nausea, shown by 
excessive paleness, often by very great languor, and by occasional 
retching, which may either subside without vomiting, or as more fre- 
quently happens, terminate in that act; flatulent distension and hard- 
ness of the abdomen, especially in the epigastric region, often accom- 



SYMPTOMS. 359 

panied with eructations; and in man}" of the cases simple diarrhoea. 
These syniptoms usually come on soon after nursing freely, or after a 
very hearty meal of artiticial food, in a child previously in good health. 
The attack seldom lasts more than a few hours or one or two days. 
The vomiting which almost always takes place, and which relieves the 
stomach from the offending cause, very often accomplishes the cure. 

Habitual indigestion in infants causes a train of symptoms which are 
different from, and much more severe than those just described. Of 
these the most important are: frequent attacks of nausea and vomit- 
ing, and of simple diarrhoea repeated for days, weeks, or months in 
succession; paleness, or some other unhealthy tint of the cutaneous 
surtace; continual restlessness and discomfort, with fretting or crying, 
particularly in the after part of the day and during the evening and 
night, in place of the natural ease and quiet of a healthy infant; con- 
stant fits of the most violent screaming from colic, sometimes lasting 
for hours; dull and languid expression of the countenance, or else an un- 
easy, contracted look, like that produced by continued suffering; more 
or less emaciation; failure of the natural growth in stature and size, so 
that the child is small and puny for its age; want of calorific power, 
causing the child to suffer unusually from cold, as shown by frequent 
coolness of the hands and feet; irregular appetite, which makes it 
necessary to tempt by frequent changes of the food, or more or less 
complete anorexia; and lastly, the various symptoms that indicate an 
impoverished state of the blood and bad nutrition. 

In some cases there are added to the above symptoms, or there fol- 
low as a consequence of the indigestion, those of gastritis or entero-col- 
itis, to be hereafter described. Indigestion probably seldom proves 
fatal in infants, except from the occurrence of some inflammatory com-' 
plication, as for instance, one of the diseases just named, or acute dis- 
ease of some other principal organ. 

Indigestion in children who have completed the first dentition may, 
as in the case of infants, be occasional or habitual. Occasional indiges- 
tion occurs in strong and vigorous, as well as in more delicate subjects. 
The attack generally begins, within a few hours or a day after the 
child has eaten some indigestible substance, with languor and chilli- 
ness in older children, and with languor and peevishness in those who 
are younger; after which there is headache, pain in the stomach in 
most of the cases, and very often a disposition to somnolence. If the 
child is attacked with vomiting soon after the appearance of these 
symptoms, and ejects the offending material, it will often seem per- 
fectly well from that time. If, however, this do not take place, fever, 
sometimes of a violent character, is almost certain to make its appear- 
ance. The pulse becomes very frequent, rising to 120, 130, 160 or over, 
and being full and resisting; the skin becomes flushed, dry and very 
hot; the appearance of the tongue is not generally changed early in 
the attack; there is considerable thirst; the child is restless and un- 
easy, tossing from side to side, or it lies in an uneasy sleep, attended 
with frequent starting and jerking of the limbs or crying out; the 



360 INDIGESTION. 

abdomen is natural, or hard and distended over the epigastric region. 
When the symptoms just described make their appearance suddenly, 
by which we mean in the co\irse of a few hours, in a child two, three, 
four or five years old, after it has eaten some indigestible substance, 
there is reason to fear an attack of convulsions. The probability of 
the occurrence of this accident is great in proportion to the earliness 
of the child's age, and the impressibility of its nervOus system. The 
attack is particularly to be apprehended, and should be carefully guarded 
against, whenever the fever is violent, especially if the pulse runs very 
high, when there are urgent complaints of headache, when the rest- 
lessness and agitation are very great, or when there is somnolence, 
with frequent startings or twitchings of the muscles. Convulsions 
sometimes occur without any previous warning, or after such slight 
signs of disorder as would fail to produce uneasiness in the parents or 
attendants. 

The symptoms produced by occasional indigestion generally con- 
tinue until nature relieves the stomach by vomiting or diarrhoea, or 
until the remedies proper in the case, the most important of which are 
evacuants, have been administered. It happens not unfrequentl}^, 
that symptoms of gastric or intestinal disorder remain for some days 
after the violence of the attack is subsided, and in some instances the 
disturbance is so great as to occasion gastritis, entero-colitis. or dysen- 
tery. 

Habitual indigestion in children who have completed the first denti- 
tion, is not at all an uncommon affection. It is a condition analoixous 
to, if not identical with, the dyspepsia of the adult. The symptoms of 
this form are the following. The general appearance of the child is 
delicate, as shown by a pallid or sallow tint of the skin, instead of the 
ruddy complexion of health, by thinness and want of proper develop- 
ment of the limbs and trunk, and by softness and flaccidity of the 
muscular tissues. There is an habitual air of languor and listlessness, 
with absence of the usual gayety and disposition to play natural to 
the age, and the child often complains of being tired. The appetite is 
feeble or uncertain, being sometimes absent, and at other times too 
great; or it is peculiar, there being a willingness to eat of dainties, but 
a refusal of food of a simple character. The tongue presents nothing 
peculiar. It is, however, more frequently somewhat furred than clean 
and natural. The temper is usually irritable and uncertain. The child 
rarely sleeps well; on the contrary, the nights are restless and much 
disturbed, the sleep being broken and interrupted by turning and roll- 
ing, by moaning or crying out, and by grinding of the teeth. These latter 
symptoms, together with picking at the nose, which is a frequent 
accompaniment, are almost always referred by the parents and nurses 
to worms, and it is often impossible to convince them to the contrary, 
even though frequent and violent doses of vermifuges have failed to 
show the existence of entozoa. The state of the bowels is uncertain. 
In some instances they are very much constipated, requiring frequent 
doses of laxatives, or careful regulation of the diet, to keep them soluble; 



DIAGNOSIS — PROGNOSIS. 361 

in Others they are inclined to be loose, and when this happens, the 
stools are often lienteric. In others, again, constipation and diarrhoea 
alternate. The abdomen is usually natural, or somewhat enlarged 
from flatulent distension; complaints of pain are not uncommon. This 
form of indigestion, like dyspepsia in the adult, is generally a very 
chronic affection, seldom lasting less than several weeks or months, 
and sometimes persisting for 3'ears. 

Diagnosis. — The occasional indigestion of infants is not likely to be 
mistaken for any other complaint. The suddenness of the attack, the 
character and quantity of the matters ejected from the stomach, the 
absence of symptoms indicating the invasion of any other disorder, the 
short duration of the symptoms, and the rapid recovery, all render the 
true nature of the case very clear. That which occurs in older children, 
on the contrar}^, is not so easy of diagnosis. In many cases the inva- 
sion is not unlike that of scarlet fever. The vomiting, the rapidity of 
the pulse, the great heat of the skin, and in some cases a certain suf- 
fusion of the integument dependent on the activity of the circulation, 
all render the case doubtful for some hours, or for a day, after which 
time the difficulty ceases, from the development of the symptoms pecu- 
liar to the disorder. We believe that not a few cases of simple angina 
are mistaken for indigestion, owing to the absence of com2)laints of sore 
throat, and the neglect of the j^h^'sician to examine that part. In such 
cases the vomiting and sudden attack of fever are ascribed, for the want 
of another mode of explaining them, to gastric derangement. The diag- 
nosis can be made only by examination of the fauces. The diagnosis 
of indigestion accompanied by convulsions, will be considered in the 
article on the latter affection. 

The habitual indigestion of infants is not likely to be confounded 
with any other disease. The absence of fever, of tenderness of the ab- 
domen on pressure, or other acute symptoms, all indicate the depend- 
ence of the disorder on functional distress of the stomach. The same 
remarks apply to this form of the disease occurring in older children, 
i^evertheless, the practitioner should never neglect to make a careful 
examination, both of the physical and rational signs, of all the impor- 
tant organs of the body, as it sometimes happens that latent disease of 
some one of them is the cause of the gastric difficulty. 

Prognosis. — The prognosis of occasional indigestion is nearly always 
favorable. It is rarely a dangerous disorder, unless accompanied by 
convulsions, or some other sign of violent disturbance of the nervous 
system. Under the latter circumstances, the prognosis should be very 
cautious, as the termination is not unfrequently fatal in consequence 
of injury done to the nervous centres. It should be recollected also 
that this form of indigestion sometimes becomes the exciting cause of 
inflammation of the stomach or intestines, in which event the prognosis 
will be that of those diseases. 

Habitual indigestion in infants is a serious complaint, and ought al- 
ways to awaken the solicitude both of the physician and parents; for 
though a simple functional disease of the stomach is probably not often 



862 INDIGESTION. 

fatal, it is exceedingly apt to prove so by the induction of gastritis, 
chronic enteritis, entero-colitis, or thrush, or by its laying the system 
open to other diseases, and rendering it less able to withstand them 
should they happen to occur. In older children it is not, according to 
our experience, so dangerous a malady. We have never, as yet, seen 
it terminate fatally. 

Treatment. — The treatment of occasional indigestion in infants ought 
to be very simple. The child has generally relieved itself by vomiting 
before the physician is called. If, however, it continues pale and lan- 
guid, with vomiting or retching, after the stomach seems to havp been 
emptied, the proper plan is to make use of remedies to calm the irrita- 
bility of that organ. This can almost always be accomplished by giv- 
ing a teaspoonful every ten or fifteen minutes of a mixture of lime-water 
and milk, consisting of one-third milk to two-thirds lime-water, or of 
equal proportions of each, or the same doses of a mixture consisting of 
equal parts of lime-water and cinnamon-water. At the same time a 
small mustard plaster, weakened with wheat ilour, or flannels wrung 
out of hot brand}^ and water, may be applied to the epigastrium, or a 
warm Indian mush poultice, in a flannel bag, laid over the whole abdo- 
men. Should these means fail to relieve the sickness, from half a drop 
to a drop of laudanum, or ten drops of paregoric, may be administered, 
and repeated, if necessary, in two hours. The child generally recovers 
its usual health after the sickness has entirely ceased. If. however, it 
remain fretful and uneasy, if it cry much as though in pain, it is prob- 
able that a portion of aliment has passed, in a partiall}^ or wholly undi- 
gested state, into the intestine. The suspicion will be confirmed if the 
abdomen is found, upon palpation and percussion, to be swelled, hard, 
and resonant from flatulent collections in the bowels. Under these cir- 
cumstances, a laxative ought to be given. The best dose is half a tea- 
spoonful or a teaspoonful of castor oil, a teaspoonful of simple or spiced 
syrup of rhubarb, or, if there have been evidences of an acid state of 
the stomach, about a quarter of a teaspoonful of the best magnesia. 

The occasional indigestion of older children demands a different and 
more energetic treatment. After ascertaining that the child has eaten 
something indigestible, we should inquire whether there has been vom- 
iting. If th«re has been none, or if only slight, it will be proper to 
give an emetic immediately. The best one under the circumstances is 
ipecacuanha. This rarely fails to produce a full effect, and does not 
perturbate the system, or irritate the stomach, like tartar emetic. It 
may be given either in powder or syrup. The dose is familiar to every 
one. If the ipecacuanha be not at hand, we may use hive s^^rup, which 
is kept in almost every house, or a teaspoonful of powdered alum ir 
honey or molasses, to be repeated, if necessary, in fifteen minutes. 
Alum is less apt to fail than either ipecacuanha or hive syrup. If the 
child continue unwell after the operation of the emetic, which is often 
the case, and particularly if the fever be considerable, a purgative 
should be given as soon as the stomach will bear it. The best dose is 
castor oil, which is the most speedy and least irritating. It may be 



TREATMENT. S6B 

£jiven in (n-aiio-e-jnice. which forms an excellent vehicle, or, if the child 
is old enough, in the froth of beer or porter. A dessertspoonful is gen- 
erallv enough. If the oil cannot be taken, we may give infusion of 
senna and manna, the fluid extract of senna mixed with spiced syrup 
of rhubarb, syrup of rhubarb alone, magnesia, to be followed by lemon- 
ade, salts and magnesia, or the former alone, or, lastly, a seidlitz pow- 
der. If the fever continue, and the cathartic fail to operate in four or 
six hours, a purgative enema ought to be given to hasten its effect, 
A bath at about 96° or 97° will almost always be found useful in these 
cases. The child should be kept in the bath from eight to twelve or 
fifteen minutes. The only circumstances which form an objection to 
this remedy are the facts of the patient being so irritable, or so fearful 
of the water, as to make it necessary to contend with him in order to 
succeed in using it. When this is the case, it had better not be em- 
ployed, and sponging with tepid water and spirit should be substituted. 
If the child complains of pain in the stomach, the application of a warm 
mush poultice over the epigastrium or whole abdomen will be found of 
much service. 

When, in this form of indigestion, the febrile reaction is violent, as 
it often is, and particularly when there are signs of great disturbance 
of the nervous system, consisting of excessive agitation, complaints of 
severe headai^he, drowsiness, moaning or crying out in the sleep, or 
twitching and jerking of the muscles, the physician should beware of a 
convulsive attack. In such cases as these, the patient ought to take a 
purgative dose of calomel (from two to three grains), or a dessert- 
spoonful of castor oil, have a warm bath at once, and soon after an in- 
jection. The remedies ought to be prompt and energetic, for the case 
is pressing. A convulsion is always a dangerous event in childhood, 
and should be prevented if possible. If calomel has been given, a ca- 
thartic dose ought to be administered about two hours afterwards, in 
order to insure an action upon the bowels, and to carry the calomel out 
of the system. These means rarely fail to afford relief in a few hours. 
The diet should be absolute during the violent stages of the attack, and 
the usual diet is to be resumed only by degrees. The drinks may be 
plain water or gum-water, taken cold. 

It not unfrequently happens that occasional indigestion is followed 
by gastritis or enteritis, or by habitual indigestion lasting for weeks or 
even months. These different sequelse must be treated according to the 
plan proper for each. 

The habitual indigestion of both infants and older children, requires a 
very different treatment from the occasional or accidental form. In 
both the indications are nearly the same. The most important are 
very careful regulation of the diet in all its details, the iise of tonics 
and stimulants to restore tone and vigor to the digestive function, the 
employment of remedies to correct the state of the bowels, whether 
they be relaxed or constipated, and attention to securing the child 
proper exercise, exposure to the air, and suitable clothing. 

If the symptoms of the disorder occur in a child at the breast, the 



364 INDIGESTION. 

milk of the nurse should be carefully examined, in order to ascertain 
whether it be good. If found to possess any unhealthy qualities, the 
nurse ought to be changed at once. Attention to this point alone will 
almost certainly cure the child. It needs no other remed}^ 

If the patient is fed wholly or in part, it is essential to regulate the 
diet to suit the state of the digestive function. Milk ought in all cases 
to form the basis of the food, unless it has been found by patient trial 
to be absolutely repugnant to the stomach. We have often found that 
infants who had been thought quite incapable of digesting cow's milk, 
could do so very readily when it was very much weakened with water. 
The usual proportions for an infant of a few months old, are half and 
half, or two parts milk for one of water. When these are found to dis- 
agree, it is well to try three, or even four or five parts of water to one 
of milk, and if the stomach digest this, as it often will, the proportion 
of milk may be slowi}^ and cautiously increased to the usual standard. 
If we conclude that milk cannot be digested by the child, it is best to 
try cream. Of this, one part to three or four of water may be given. 
When neither of these can be taken, some of the farinaceous subs-tances 
may be tried ; arrowroot, sago, barley, tapioca, oatmeal, or rice. We 
are clearly of opinion, however, that these articles prepared with water 
alone, never agree with children when they are continued for any con- 
siderable length of time. Some infants of six or eight months old, it 
ma}' be remarked, who cannot digest more than very small quantities 
of milk, will take and digest well, verj^ delicate broths made of chicken 
or mutton, or small quantities of the lightest meats, as mutton, chicken, 
or very tender beef, minced up extremely fine, and given by tea- 
spoonfuls. 

In cases of this kind we have found a diet consisting of gelatin, milk, 
cream, and arrow^root, prepared in the manner directed in the article 
on thrush (see p. 338), to suit better than anj'thing else. We have met 
with a number of children, whom it was necessary to feed to the amount 
of a pint or a pint and a half a day, in addition to their being nursed 
occasionally, who could take neither milk and w^ater, cream and water, 
milk and arrowroot, oatmeal gruel, rice gruel, nor indeed anything that 
w^as tried, without vomiting, colic, and severe diarrhoea, who digested 
perfectly well and throve admirably upon the preparation alluded to. 
We have now used it during many years, and have recommended it for 
a great many childi-en, and do not hesitate to say that it agrees with 
a larger number than anj^ diet we have employed or seen employed. 

The diet of older children laboring under chronic weakness of the 
digestive function is as important as that of infants. Two chief ends 
should always be borne in mind in selecting it, digestibility and nutri- 
tiousness. The former is all-important, for without it, the stomach, 
constantly irritated b}' improper food, has no chance of regaining its 
tone, while the latter is necessary in order to sustain the strength of 
the child, and allow it to carry on its growth. We have generallj' found 
it most prudent, and often really necessary, to specify as to the sub- 
stances to be given at each meal. The morning and evening meal ought 



TREATMENT. S65 

to consist of bread and milk, mnsh and milk, or of milk, warm water 
and siio-ar (called in this countrj^ children's or cambric tea), and bread 
and butter, and nothing else in most of the cases. It is sometimes proper 
to allow a soft-boiled egg, ^^-'^I'ticularly if the child be very fond of it. 
The dinner ought to consist of light broths containing rice, with bread 
or toast, or of the plain meats, as mutton, beef, chicken, turkey, birds, or 
fine game. ]S^o vegetable ought to be allowed in most of the cases except 
rice, as all others, even the potato, are very apt to disagree. We be- 
lieve that the potato is jnore digestible when roasted than when boiled. 
If the child require anything between breakfast and dinner, it may have 
what is allowed at breakfast, or dry bread and nothing else. There are 
various articles of diet which should be absolutely forbidden, amongst 
which are hot and sweet cakes, and hot bread of all kinds; sausages, 
not unfrequently given to children in this country ; corn-beef, ham, veal, 
pork, goose, ducks, fish; all manner of dessert, excepting rice-pudding, 
or curds-and-whey, often called junket ; sweetmeats, candies, fruits, 
except some of our finest summer ones; and to conclude, everything 
which long observation and experience have shown to be unsuitable to 
a dyspeptic stomach. 

It is sometimes very difficult to find anything to agree well with the 
child. In one case of a child three years old that came under our ob- 
servation, neither milk, bread, nor meat, could be taken. The casein 
of milk seemed to be absolutely indigestible, as it would be rejected 
from the stomach manj^ hours, or even a day or two after the milk had 
been taken, in the form of masses of dry, fibrous cheese, of an oblong 
shape, nearly or quite as large as a peachstone. After trying various 
articles, we found that the child digested raw oysters, soda-biscuit, and 
rennet-whey, and upon these articles alone she lived for two weeks, at 
the end of which time she had improved so much as to be able to take 
the white meat of chicken very fiuely minced. She gradually regained 
her previous health. 

After regulating the diet, such remedies as tend to invigorate the 
digestive functions ought to be prescribed. The most important of 
these are the vegetable and mineral tonics, and mild stimulants. We 
have found quinine, iron, and small quantities of port wine or brandy, 
to succeed better than anything else. To a child under two years old, 
from a quarter to half a grain of quinine, and to one over that age, a 
grain, may be given three times a day, and continued for two, three, 
or four weeks. It is best given to young children diffused, without 
being dissolved, in a mixture of equal parts of syrup of gum and 
ginger; while to those who are older it may be administered in pill. 
The best preparations of iron are the syrup of the iodide, or the pure 
metallic iron, prepared with hydrogen. Of the former, half a drop to 
one drop for infants, and from two to four drops for older children, may 
be given three times a day ; of the latter a quarter of a grain for infants, 
and half a grain to a grain for those who are above that age, may be 
given three times a day. The metallic iron is best administered in pill, 



366 INDIGESTION. 

or suspended in syrup of gum arable. When there is any suspicion of 
a scrofulous taint in the child's constitution, or when it is disposed to 
have chronic irritations, excoriations, or ulcerations of the nostrils, 
otorrhoea, or papules or pustules about the eyelids or other parts of the 
body, it is useful to give the iron in compound syrup of sarsaparilla, of 
which half a teaspoonful three times a day is quite enough. Under 
these circumstances, and particularly when the dyspej^tic condition is 
accompanied with frequent nausea or occasional vomiting, with fronta 
headache, and Avith constipation, seeming to indicate a disposition to 
tubercular deposit in the sj^stem, wo have found cod-liver oil the most 
efficient of all the remedies that we have tried. It has often removed 
with great rapidity the dyspeptic symptoms, invigorated the general 
health, and, in fact, restored the patient to health. The dose is from 
half a teaspoonful to a teaspoonful twice or three times a day, at the 
age of six or eight years. It is best taken in a small quantity of malt 
liquor, or floating on strong mint-water, or syrup of ginger. In very 
young children, and in older ones also, when the latter refuse to take 
it in the ordinarj:" methods, the following formula for its administra- 
tion will be found one of the best : 

R.— 01. Jec. Aselli, f^ss. 

P. G. Acacise, q. s. 

01. Cinnamomi, vel 01. Gaultherise, . . gtt. vj. 

Sacch. Alb., q. s. 

Aq. Cinnamomi, ad f^iij. 

Ft. mistura. 
Dose, a dessertspoonful three times a day, after eating. 

The recent introduction of the use of pepsin in the treatment of dis- 
orders which, like the one under consideration, are characterized by a 
want of digestive power, is a most valuable improvement in their man- 
agement. It is nearly always perfectly well received by the stomach, 
and in very many cases will enable the child to take and thoroughly 
digest the proper amount of suitable food, which before would have in- 
evitably caused evidences of gastric embarrassment, with the rejection 
of a considerable part of the meal in an undigested state by vomiting 
or stool. 

Pepsin may be administered in the form of powder — the best prepa- 
ration of which is that now sold under the name of saccharated pep- 
sin — and the proper dose of which for a young child is two or three 
grains taken immediately after meals. Or we may use the liquor pep- 
sina?, which is a solution of this substance in glycerin and water, acidu- 
lated with muriatic acid. The proper dose of this latter preparation is 
from Ti^xx to f5ss., taken diluted with a little water, also directly after 
meals. 

The combination of small doses of muriatic acid is unquestionably of 
advantage in increasing the digestive power of the stomach. We have 



SIMPLE DIARRH(EA. 367 

thus found the following mixture of much service in the chronic indi- 
gestion of children : 

R- — Acid. Muriatic. Diluti, gtt. xxv. 

Liquor Pepsinae, 

Elix. CalisaynB, aa, f^j. — M. 

Dose, from a half teaspoonful to a teaspoonful, according to the age of the child. 

In connection with these remedies, a little port wine or brandy, and 
the former is preferable in children over a few years old, on account of 
the possibility of their contracting a taste for the brand}^, may be al- 
lowed twice or three times a day, or at dinner only. To young chil- 
dren, one or two teaspoonfuls of brandy may be given in the course of 
the day, mixed in water; of the port wine, from a teaspoonful to a 
tablespoonful, according to the age and strength of the patient, maybe 
repeated morning, noon, and night. 

If the bowels are inclined to constipation, they should be kept soluble 
by laxative eneraata, and by the use of rhubarb or aloes; when relaxed, 
the frequency of the discharges may be controlled by the cretaceous 
mixture, by anodyne enemata given once or twice a day, by the aroma- 
tic syrup of galls (to be described under the head of entero-colitis), or 
b}" some of the astringents in common use. 

In all cases of chronic indigestion in children, it ought to be regarded 
as an essential part of the treatment to secure to the patient a proper 
amount of exercise in the open air. In summer the child should pass 
several hours of every day in the air. It ought, indeed, if the heat of 
the sun can be avoided by proper shade, to pass the whole day in this 
way. In winter it is, of course, impossible to carry this system to the 
same extent, but the child should nevertheless be taken out at least 
once a day; this may be done in the coldest, and even in damp 
weather, if sufficient clothing be worn. If a child comes back from a 
walk with w^arm limbs, and with its cheeks in a glow, there is little 
danger of cold. The quantity of clothing must depend on the consti- 
tution and idiosyncrasy of the patient. Some need twice as much as 
others. The proper amount is best determined by the temperature and 
coloration of the surface after a walk. 



AETICLE II. 

SIMPLE DIARRHOEA. 

Under this title we shall describe a mild form of diarrhoea to which 
children are very subject, in which the pathological condition appears 
to be one of mere functional disorder, or of very moderate hypera^mia 
or catarrh of the intestinal mucous membrane. We might, indeed, as- 
sume with some, that the disorder is at all times one of mild catarrh 
of the bowels, but we deem it best, in a practical point of view, to con- 
sider it as being sometimes one of functional disturbance only, since 



368 SIMPLE DIARRHOEA. 

many observers of high authority declare that they meet with cases of 
even fatal diarrhoea in which no anatomical alterations are found after 
death, and since we ourselves have met with so many cases in practice 
which follow a different course in sj^mptomatology, duration, and their 
effects upon the constitution, from the form of disease which we shall 
treat of as entero-colitis or inflammatory diarrhoea. 

Causes. — The causes of the disease during infancy are unfavorable 
hygienic conditions, as the habitation of unwholesome, ill-ventilated, 
damp, and filthy dwellings, or of contracted and crowded quarters of 
cities and towns; an unhealthy state of the milk of the nurse; the use of 
artificial diet at too early an age, especially that of an improper kind; 
cold; dentition; and lastly, great atmospheric heats. The most impor- 
tant of these are improper alimentation, by which we mean the use of 
artificial diet, and particularly one consisting chiefly of farinaceous sub- 
stances to the exclusion of a proper amount of milk, and dentition. 
For a fuller account of the influence of these different circumstances on 
the digestive organs of children, the reader is referred to the remarks 
on the causes of entero-colitis, and to the article on thrush. 

The chief causes of the disease after the first dentition are, according 
to our experience: the habitual use of improper food ; the loss of diges- 
tive power, which often follows a severe indigestion, or an attack of 
some acute disease; the debility of constitution which attends sudden and 
rapid growth; the ?^flfn^ of proper exercise and exposure to the air; 
the predisposition which exists in some children from hereditary causes; 
and the disturbing influence of the second dentition. 

The sj^stem of indiscriminate diet allowed to children in this country 
is. it seems to us, a fruitful cause of gastric and intestinal complaints. 
We believe that, as a general rule, children over two and three years 
of age, are allowed amongst us to eat of the food prepared for the older 
members of the family. Now, any one who will reflect upon the variety 
of dishes habitually placed upon an American table, ought not to be 
surprised to see children permitted a choice amidst such profusion, pale, 
thin, delicate, exposed to frequent indigestions, attacks of diarrhoea 
and entero-colitis, to gastric fevers, and the host of minor ills attendant 
upon feeble digestive powers. We are acquainted with some families 
in this city, the children of which, from the age of two years, are 
allowed habitually to breakfast upon hot rolls and butter, hot buck- 
wheat cakes, hot Indian cakes, rice cakes, sausages, salt fish, ham, or 
dried beef, and coffee or tea : and to dine upon a choice of various meats 
and a great variety of vegetables, which latter they often prefer to the 
exclusion of meat, and then to make a rich dessert of pies, puddings, 
preserves, or fruits; and lastl}" to make an evening meal of tea and 
bread and butter, almost always relished, as the term is, with preserves, 
stewed fruits, hot cakes of some kind, or with radishes, cucumbers, or 
some similar dish. Add to such meals as the above, the eating between 
whiles of all kinds of candies and comfits, which* many children here 
regularly expect in larger or smaller quantity, cakes both rich and 
l^lain, fruits to excess and at all hours, from soon after breakfast to just 



ANATOMICAL APPEARANOES. 369 

before goin^ to bed, raisins and almonds, and nuts of various kinds, 
and the wonder is, not that we are a pale, thin, dyspeptic, and anxious- 
looking race of people, compared with Europeans, but that we have 
any health at all, Avhen our children are allowed to make use of the 
indiscriminate and unwholesome diet just described. Such a system 
undoubtedly occasions frequent attacks of the disease under consider- 
ation, and unless the diet be changed early in the attack, it is very apt 
to become chronic. It has been stated that simple diarrhoea sometimes 
followed as a consequence of indigestion. We have known such a re- 
sult to occur in children previously in fine health, and to continue for 
several weeks or months. In these instances, the disorder appears to 
depend in good measure on the loss of the digestive power of the 
stomach. This seems proved by the great influence w^hich the charac- 
ter of the food has upon the malady, which is alwaj'S aggravated by 
the use of any articles except those universally acknowledged to be the 
most digestible, and also by the frequent coexistence of lieutery when 
the food is not of the lightest kind. 

We have several times met with cases which we could ascribe to no 
other cause than debility and want of power of the digestive organs, 
dependent upon too rapid growth. That sudden and rapid growth may 
produce feeble digestion, or, in other words, a dj^speptic state, is, in 
our opinion, proved bj^ the following consideration. It is attended with 
loss of appetite, emaciation, paleness, languor, and weakness, and fre- 
quent attacks of diarrhoea, or a chronic form of that disorder; all of 
which symptoms are greatly influenced by the regimen of the child, 
and are most readily removed by attention to that point, and by the 
use of tonics and stimulants. 

The other causes enumerated need but little comment. We will 
merely remark that we have several times observed a predisposition to 
weakness of the digestive organs, transmitted apparently from parent 
to child. As to the influence of the second dentition, we have no doubt 
that it is a frequent cause of the complaint, and w^e believe that it is 
too little attended to by practitioners. 

Anatomical Appearances. — It has already been stated that we look 
upon this disorder as one of purely functional disturbance in many in- 
stances. We are led to take this view bj^ the fact that it is so often 
unattended by any of the ordinary signs of inflammatory action, and 
because some very competent observers affirm that they have failed to 
find in a certain proportion of cases of fatal diarrhoea, any lesions ap- 
j)reciable to the senses. Thus, M. Billard saj^s {Mai. des Enfants, p. 392): 
" Many children at the breast have diarrhoea without enteritis; they 
lose color, become etiolated, fall into a state of marasmus, and yet at 
the autopsy not a trace of inflammation of the intestines is found." 
M. Bertin {3fal. des Enfants, 2eme ed., p. 574) states that of 57 cases of 
gastro-intestinal disease observed by himself, there were four in which 
not a trace of inflammation, or any other appreciable lesion of the 
digestive tube, could be found. MM. Eilliet and Barthez, in their first 
edition (t. i, p. 491) assert that in about every twelve children affected 

24 



370 • SIMPLE DIARRHCEA. 

with more or less abundant diarrhoea, and in whom we might expect to 
find colitis, there will be one in whom the gastro-intestinal tube will 
be found in a state of perfect integrity. They add that this conclusion 
is deduced from a comparison of nearly three hundred autopsies. We 
do not find this statement given in their second edition, but we do find 
there (t. i, p. 693) the following paragraph : ^' Quite frequently, espe- 
cially in early infancy, in cases in which the symptoms have pointed to 
some disease of the gastro-intestinal tube, an autopsy reveals no lesion 
of the solids, or only changes of minimum importance. The secretions 
alone are vitiated." One must suppose, therefore, that the class of cases 
which we describe as simple diarrhoea, are sometimes quite independent 
of any anatomical changes in the tissues, recognizable by our ordinary 
methods of examination, or that those changes are so slight and so 
evanescent as to disappear after death ; or that they are those only of 
the mildest forms of catarrhal inflammation. It is not unlikely, it 
seems to us, that farther and more minute investigation, especially with 
the microscope, will reveal tissue-changes which are not discoverable 
by the unassisted senses. 

When the anatomical changes, constituting the catarrhal state, are 
found in children who presented during life the symptoms of simple 
diarrhoea, they will be such as are described byNiemeyer in the follow- 
ing passage : " Catarrh rarely affects the entire intestinal canal. It is 
most frequent in the large intestine, less so in the ileum, and rarest in 
the jejunum and duodenum. The anatomical changes left in the cadaver 
by acute catarrh, are sometimes pale, at others dark redness, swelling, 
relaxation, and friability of -the mucous membrane, which is sometimes 
diffuse, at others limited to the vicinity of the solitary glands and of 
Peyer's patches, and a serous infiltration of the submucous tissue. Oc- 
casionally, after death, the injection has entirely disappeared, and the 
mucous membrane appears pale and bloodless. Swelling of the solitary 
glands and glands of Peyer is an almost constant appearance; they 
distinctly project above the surface of the mucous membrane. The 
mesenteric glands also are usually found hypersemic and somewhat en- 
larged. The contents of the intestines consist at first of plentiful serous 
fluid, mixed with detached epithelial and young cells, subsequently of 
a cloudy mucus, which is adherent to the wall of the intestine, and 
contains e2:)ithelial structures." 

The best description that we are acquainted with of the anatomical 
appearances found in the intestines in fatal cases of diarrhoea, not in 
children, to be sure, but in adults, is that given by Dr. Woodward 
in his work on Camp Diseases (Philadelphia, 1863). In that work 
(page 216), under the head of simple diarrhoea, he says that this form 
of diarrhoea is to be regarded as usually the result of irritation of the 
intestinal mucous membrane, produced by the ingestion of improper 
food, or other causes mentioned, and expressing itself in increased 
secretion throughout the intestinal tract. The irritation, he goes on 
to say, ma}^ even amount to inflammation. Opportunities for post- 
mortem examination occur but rarely. "The}' reveal little that bears 



SYMPTOMS. 371 

on the nature of the disease, except congestion of the intestinal vessels 
of variable intensity." At page 246, will be found a description of the 
histoloiry of the intestinal lesion in chronic diarrhoea, including the 
chano-es observed in specimens but moderately diseased, which latter 
would probably be the analogue of what we might expect to find in 
the simple diarrhoea of children we are now describing. ' We must refer 
the reader to the work itself, as the passage is too long to be quoted in 
full here; but we cannot help thinking that Dr. Woodward's descrip- 
tions would appl}' also to the changes induced in children by like 
causes, and leading to similar forms of disease. 

Symptoms. — We shall describe first the sj-mptoms of simple diarrhoea 
in infants, and afterwards those which characterize the disorder in older 
children. In infants the appearance of the diarrhoea is usually pre- 
ceded or accompanied by slight disturbance of the temper and comfort of 
the child. There is some degree of restlessness, peevishness, and disposi- 
tion to cry; the child sleeps less than usual, and often starts and moans 
during sleep; all of which symptoms are more marked, as is the case 
indeed in nearly all the ailments of children, during the night. Though 
the symptoms described are observed from time to time, and particu- 
larly during the night, they are not always present, as the infant will 
occasionally through the day seem perfectly well and comfortable, 
with the exception, perhaps, of slight paleness and languor, almost 
always perceptible upon its countenance. There is no fever in these 
cases, or at least nothing more than unusual warmth of the hands, 
feet, and abdomen at night. If a marked febrile reaction take place, 
there would be reason to suspect the existence of some degree of 
entero-colitis. The mouth often becomes, after a few days, a little 
warmer and less moist than usual; the tongue is generally moist and only 
slightly coated; and the appetite is commonly diminished, as shown by 
the child's nursing with less eagerness and at longer intervals than be- 
fore. In very mild cases the stools are at first, and sometimes throughout 
the attack, feculent; the only diiferences from their ordinary characters 
are that they are more frequent, thinner, more copious than usual, and 
that the odor is changed so as to become acrid and offensive. In severe 
cases, they contain less feculent matter, become yet more fluid and 
sometimes watery, and exhibit small particles of a greenish color 
scattered through them; or the whole of the discharge is of a deep green 
color, and it is intermixed with portions of mucus. In many of the 
cases, whitish lumps, evidently consisting of undigested curd, are 
observed mixed with the other substances upon the napkin. The 
number of stools varies from two, three, or four, to six or eight in the 
twenty-four hours. The number last mentioned is seldom exceeded, 
so long as the diarrhoea remains simple. The abdomen is seldom dis- 
tended or painful to the touch. The general appearance of the child 
almost always shows the effects of the malady upon the constitution 
after a few days. The countenance becomes paler and thinner; the 
eyes look somewhat hollow; the edges of the orbits are more defined, 
and often present a pale bluish circle; slight emaciation takes place. 



372 SIMPLE DIARRHCEA. 

and the flesh of the child becomes softer and more relaxed than before 
the attack. The duration of the disorder is generally short, as it sel- 
dom lasts more than three or four days or a week. It may terminate 
in complete restoration to health, without having exposed the life of the 
child to danger, or, if the causes which gave rise to it continue in action, 
if the child is of delicate constitution or the treatment not correct, and 
especially if this is of too perturbating a character, it is very apt to run 
into entero-colitis and expose the patient to all the dangers of that dis- 
ease. 

In older children (after the first dentition), the disease is much less 
frequent than in infants, and presents a diiferent train of symptoms. 
Often it is nothing more than a slight disorder of the bowels, amount- 
ing to three, four, or five stools, thinner and more abundant than usual, 
accompanied by slight colicky pains, and unattended by fever or other 
signs of sickness, which, after continuing one, two, or three days, 
ceases, and the child regains its usual health. Some children are j^ar- 
ticularly liable to these attacks, and suffer from them every few weeks, 
or after any indiscretion in diet; whilst in others they are rare, let the 
diet be what it may. 

There is another form of simple diarrhoea, however, of which we have 
seen a number of cases, much more troublesome than the one just de- 
scribed. It occurs in children from two and a half to seven and eight 
years of age, lasts a considerably longer time, and is much less under 
the control of remedial measures. This form of the disease has never, 
in the cases that we hav^e seen, been accompanied by fever, or by any 
constitutional symptoms rendering it necessary to confine the child 
either to the bed or house. The only symptoms besides the diarrhoea 
which we have observed, have been some degree of paleness and mod- 
erate emaciation; slight weakness, shown by an indisposition on the 
part of the child to play with its usual spii"it, by an inclination to lie 
about from time to time through the day on the sofa or floor, and by 
complaints of "being tired;" irritability of temper and peevishness; 
irregular appetite; picking of the nose; and restless, disturbed sleep at 
night, attended with moaning, crying, starting, and grinding of the 
teeth; all of which symptoms generally convince the mother that the 
child is sufl'ering from worms. The abdomen is sometimes slightly 
tumid, but remains natural as to tension, and is not painful on pres- 
sure. There is no pain except slight colic in some cases. The stools 
have generally numbered from three to five, and in a few cases as 
many as six or eight a day. They are semifluid in consistence, often 
of a very offensive odor, and consist usually of feculent matter, which 
is sometimes clay-colored, more frequently dark brown, and, in other 
instances, deep yellow or orange in color. They are often also of a 
frothy character. In some of the cases that we have seen, there was 
lientery whenever the aliment was otherwise than of the lightest and 
most digestible kind. In all, the diarrhoea was evidently greatly in- 
fluenced by the diet, showing, it appeared to us, a manifest dependence 



DIAGNOSIS — PROGNOSIS — TREATMENT. 373 

of the malady upon the condition of the stomach, which seemed to 
have lost to a great degree its digestive power. 

The course of the disease in this form is variable. In some it lasts a 
few weeks, and then, under the influence of diet and remedies, ceases, 
to recur and run the same course after a short period. In others it may 
last a much longer time in spite of all treatment that we attempted. 
We have known it to thus continue between three and four months, 
with occasional slight remissions, brought about apparently by remedies 
which a day or two after would lose their effect. 

Diagnosis. — The diagnosis of simple diarrhoea will rarely present 
any difficulties^ since there is nothing with which it could be con- 
founded, except tlie diarrhoea from tubercular ulceration of the bowels, or 
entero-colitis. From the former it is to be distinguished by the history 
of the case, and by the signs of tuberculosis in other parts of the econ- 
omy; from the latter, by the absence of signs of inflammatory action. 

Prognosis. — The prognosis is favorable so long as the disease remains 
simple. The physician should never forget, however, the disposition 
which is inherent in it to pass into entero-colitis, nor fail to make the 
possible occurrence of this transition one element in his prognosis. 
During infancy it is always more serious than after that period, from 
the feebler power of resistance on the part of the constitution at that 
age to disease, which undoubtedly allows this simple affection to prove 
fatal in some instances, probably from the shock to the nervous sj^stem. 
After infancy it is rarelj^ a dangerous disorder, both because of the 
greater stamina existing at that age, and from the fact that the dispo- 
sition to the extension of disease is less strong. 

Treatment. — The prophylactic management of simple diarrhoea is the 
same as that which is proper for entero-colitis, and as that affection 
will be treated of at considerable length in a future article, we must on 
account of our limited space, refer the reader there for information on 
this point. 

After the disease is established, the treatment must consist first in 
attention to the dlet^ exercise^ and state of the gums of the child. In 
many cases, careful regulation of the diet and exercise, and lancing the 
gums when they are much distended and vascular from the pressure of 
the advancing teeth, will suffice to arrest the disorder in a few days, 
without the necessity of resorting to drugs, which ought certainly to 
be avoided whenever it is possible to do so. If the child is at the 
breast, we must ascertain whether the milk of the nurse is good, by 
inquiry as to its appearance, specific gravity, reaction, and by exami- 
nation with the microscope, and by reference to her health, diet, tem- 
per, &c., all of which circumstances more or less affect the mammary 
secretion. If we conclude that the milk is good, or that it has been 
disturbed in its healthy properties only by a transient cause, the child 
must be continued at the breast, with the precaution, however, of not 
allowing it to nurse quite so much as usual. An infant suffering from 
any kind of diarrhoea, had better be restricted entirelj^ to the breast, 
unless it be clear that the supply of milk is quite insufficient. If we 



374 SIMPLE DIARRHCEA. 

determine that the milk is unhealthy, the nurse must either be changed, 
or the child weaned ; of course the former alternative is infinitely 
preferable if the child is under a year old, or even under eighteen 
months, if it seem to have a rather delicate constitution. 

If the case occur in a child already weaned, or in one fed partly on 
artificial diet, the regulation of the kind, preparation, and quantity of 
aliment is of the utmost consequence. It ought to consist chiefly of 
milk or cream weakened with water, unless it has been clearly shown 
by previous trial that these articles do not agree with the child. We 
prefer before any kind of diet that we have ever employed, or known 
to be employed, that made from cow's milk, cream^ arrowroot, and gel- 
atin, in the manner described at page 338. The proportions of the 
milk, cream, and arrowroot must vary wath the age and digestive 
power of the patient. As a general principle, during the existence of 
diarrhoea, or at least in the early stage of it, and before the strength 
has been reduced by the disorder, the proportions of cream and milk 
ought to be somewhat less than in health. Not only so, but the total 
quantity of food in the day should be diminished, unless the ordinary 
amount seems to be really necessary for the sustentation of the strength. 
If it be found, after patient trial, that the child will not take, or does 
not digest this kind of food, we may try arrowroot or rice-water, with 
a little cream, or thin gruel or panada, alternated with very carefully 
prepared chicken- or mutton- water. If the child is six or eight 
months old, it often suits well to allow it a piece of juicy beef or a 
chicken-bone to suck, or from one to several teaspoon fuls of meat of 
chicken or mutton minced very fine. 

For older children with a common attack of simple diarrhoea, the 
diet should consist for a few days of boiled milk with bread, of gruels 
made of boiled milk and arrowroot, rice-flour, sago, tapioca, or common 
wheat flour, and of small quantities of light broths. Meats are, for the 
time, improper, and all vegetables, with the exception of rice, yet worse. 

In the case of infants it is best to recommend a continuation of the 
ordinary exercise, unless the weather be cold and damp. Indeed, in 
good weather, exposure to the air and proper insolation are more im- 
portant during the existence of this disorder than even during health. 
The same remarks apply to older children, with the exception that 
they ought not to be allowed to fatigue themselves, particularly in 
warm weather, as this tends to aggravate the complaint. 

When the disorder occurs in a teething child, the gums ought 
always to be examined by the physician, and if found swelled, vascular, 
of a deep red color, and hot, with the outline of the advancing tooth 
perceptible, the}^ should be freely incised to the tooth. If, on the con- 
trary, the tooth is too deep to be felt, and yet the gum is red and 
swelled, we would advise only a slight and superficial scarification in 
order to relieve the tension. 

The therapeutical management of the disease should be as simple as 
possible. The fewer drugs we can succeed with in the gastro-intestinal 
complaints of infants and children, the better. When, however, the 



TREATMENT. 375 

diarrhoea continues for some days in spite of attention to the points 
already mentioned, and earlier if the discharges are either large, fre-' 
qnent, yevy watery, or weakening to the child, we must resort to some 
of the means which have been found most useful in checking the inor- 
dinate action of the bowels. The most important are a careful em- 
ployment of laxatives, and the use of opiates and astringents. For- 
merl}' we generally commenced the treatment by the exhibition of a 
teaspoonful of castor oil, containing from half a drop to a droj) of 
laudanum, for young infants, and two drops for older children : but of 
late years we have usually preferred the spiced syrup of rhubarb, in a 
teaspoonful dose, with laudanum, as above recommended. Castor oil 
sometimes purges more than we like; rhubarb rarely does so. These 
doses o-iven for two eveniuo-s in succession have oftentimes sufficed to 
effect the cure. Dr. West recommends very highly in cases of simple 
diarrhoea, in which the evacuations, though watery, are fecal, and con- 
tain little mucus and no blood, small doses of the sulphate of magnesia 
and tincture of rhubarb. His formula at one year of age is as follows : 

R- — Magnes. Sulphat., 3;j. 

Tinct. Ehei, f^ij. 

Syr. Zingiber., f^j. 

Aquse Carui, f^i^- — ^^ 

Dose, a teaspoonful. 

"We often use with excellent effect the sulphate of magnesia, with 
laudanum, as follows: 

R. — Magnes. Sulphat , ^j. 

Tr. Opii Deodorat., ....... gtt. xij. 

Syrup. Simp., f.^ss. 

Aquse Menth. vel Cinnamom., ..... f^ijss. — M. 
Dose, at one or two years a teaspoonful every two or three hours. For older chil- 
dren, the proportion of the magnesia and laudanum should be doubled. 

If the diarrhoea persists after these means have been used for two or 
three days, or gets rapidly worse, we must resort to some of the astrin- 
gents. The one most commonly emploj^ed is the chalk mixture, which 
is officinal in our Pharmacopoeia. A teaspoonful of this is to be given 
after each loose evacuation, or three or four times a day. If the case 
prove obstinate, it will be found useful to add to each dose of the chalk 
preparation, a small quantity of laudanum or paregoric, or some astrin- 
gent tincture, the best of which is the tincture of krameria. When 
the chalk mixture fails entirely, powdered crab's-eyes will sometimes 
succeed; or we may resort to the aromatic syrup of nutgalls. The for- 
mulae and doses for both these remedies will be found in the article on 
entero-colitis. If the discharges are small and frequent, mixed with 
mucus and somewhat painful, it will be found that small opiate injec- 
tions (from one to two drops of laudanum in a tablespoonful of starch- 
water for young infants, and from three to six drops in double that 
quantity for older children), or the use of Dover's powder in combiua- 



376 SIMPLE DIARRHCEA. 

tion with chalk or sugar of lead, will often succeed in arresting the 
disease. One of the raost valuable astringents in the bowel affections 
of young children is bismuth, which we are much in the habit of giving 
in the form of subnitrate in doses of from two to five grains, according 
to the age, from three to six times in the course of twenty-four hours. 
For further and more complete information in regard to astringents, 
we must refer the reader to the article on entero-colitis, where they 
will be fully discussed. 

The chronic form of simple diarrhoea which we have attempted to 
describe, occurring in children who have completed the first dentition, 
has always proved difficult to manage. From the experience we have 
had, we believe that the best mode of treating it is by proper regula- 
tion of the diet, and by the use of tonics and stimulants, and occasion- 
ally of opiates. We were led to adopt this plan in consequence of 
having failed entirely to control the symptoms by the treatment gen- 
erally successful in simple diarrhoea, and by the opinion which wo 
came at last to form, that the disease depended in great part on a loss 
of the digestive power of the stomach and duodenum. The diet must 
be adapted to the idiosyncrasies of the individual; what we should seek 
is such a one as will be easily digested by the patient, the materials of 
which shall not appear in the stools, and one which does not manifestly 
increase, if it fail to moderate, the frequency of the discharges. The 
one which we have found to succeed best, consists of boiled milk with 
stale bread for breakfast and tea, and the tenderest meats, as very fine 
beef, mutton, chicken, or birds, with rice, as the only vegetable, for 
dinner. If the child likes flour or rice pap, it may have either in place 
of the bread and milk. If it will take none of these, it may have milk, 
warm water and sugar, with bread; or well-boiled mush with milk, or 
milk toast. Should it refuse the dinner recommended above, we may 
substitute delicate soup, or some of the milk preparations. Eaw meat, 
given in the manner recommended in the article on entero-colitis, 
should also be tried, and will at times prove very beneficial. Between 
meals it ought to be allowed nothing but dry bread. All rich food, 
dessert, fruits, all vegetables except rice, candies and comfits, all kinds 
of cake and hot bread, in fact everything except the articles which we 
have mentioned, or similar ones, ought to be rigidly, systematically, 
and perseveringly forbidden. Until this has been done for many days, 
or for several weeks, the disease has always, according to our experi- 
ence, obstinately persisted. 

We have already said that we have not found the ordinary remedies 
for simple diarrhoea to exert much effect upon this form of the disease. 
On the contrar}^ the treatment for dyspepsia, that is to say, a simple 
but nutritious diet, exercise, and the use of tonics and stimulants, has 
always removed it in a longer or shorter time. The tonics which we 
have employed are port wine, quinine, and iron. From a dessert to a 
tablespoonful of port wine was usually given in water three times a day, 
in connection with iron. The preparations of iron used were Yallet's 
mass, of which from half a grain to a grain was given in pill three 



GASTRITIS. 377 

times a day; the solution of iodide of iron in the dose of first one, and 
then from two to four drops, three times a day, or the solution of the 
nitrate of iron in the dose of from two to five drops, three times a day, 
in water, continued for one or two months. We have sometimes com- 
bined with each dose of the solution of iron a drop of laudanum, especi- 
ally if there were pain; or the opiate mio-bt be given by injection every 
evening. The quinine was generally administered alone in the dose of 
a grain three times a day, for one, two, or three weeks. It has not, 
however, proved so useful as port wine and iron. 

Another tonic which we have found very useful in some cases of this 
kind, of late years, is one containing nux vomica and compound tinc- 
ture of gentian, as follows : 

R. — Tr. I^acis Yomic, f^ss. 

Tr. Gentian Coinp., , . . . ... . f^iij. 

Syrup. Simp., f^v, 

Aquie, ff ij — M. 

Dose, a teaspoonful three times a da}' after meals, for children of three or four 
years of age. 

AVine of 2:)epsin, in half teaspoonful doses, three times a daj", is also 
a good remedy in such cases, or we may use the powdered saccharated 
pepsin, in doses of two to five grains, taken soon after each meaL 

In the case attended with all the symptoms usually thought to indi- 
cate worms, the use of wormseed oil was followed by the expulsion of 
several very large lumbricoides. The child did not recover, however, 
for some weeks afterwards, and not until he had taken port wine and 
quinine for a considerable period. In other cases in w^hich the vermin- 
ous symptoms w^ere also strongly marked, and in which the same rem- 
edy was given, no worms w^ere expelled. 



SECTION II. 

DISEASES OF THE STOMACH AND INTESTINES, ATTENDED WITH APPRECIABLE 

ANATOMICAL LESIONS. 

ARTICLE I. 

GASTRITIS. 

Gastritis, in the sense in which the term was used some ten or 
twenty years since, viz., to express an individual and special inflam- 
mator}- disease of the stomach, of common occurrence and of supposed 
great severity and importance in childhood, is now well known to be a 
rare affection. It is doubtful, indeed, whether it ever forms a special 



878 GASTRITIS. 

visceral inflammation, except in consequence of the direct application 
to the organ of some irritant substance, such as the mineral acids or 
arsenic, or, as Eilliet and Barthez found, in a few instances, certain 
remedial agents, as tartar emetic, kermes mineral, and croton oil. In 
the form of catarrh, acute or chronic, of the mucous membrane, on the 
other hand, it is doubtless one of the most common affections of child- 
hood, constituting an important element in a great many diseases, and 
especially in the severe forms of indigestion, in simple and inflamma- 
tory' diarrhoea, in cholera infantum, and in many of the wasting diseases 
of childhood, which result from the use of improper artificial diet in 
infants, and of crude and indigestible articles of food in older children. 

We had almost abandoned the plan followed in our former editions, of 
devoting a special chapter to this subject, but, on further consideration, 
think it will be best to treat of it separately, since, as stated above, 
cases do occur in practice in which the stomach is the chief, if not the 
only seat of disease, and which can be properly designated and described 
only under the title of gastritis. 

Causes. — Tt has already been stated that the most violent and typi- 
cal cases of gastritis, as a distinct disease, are the result of the appli- 
cation to the organ of some special irritant, as the mineral acids, 
arsenic, boiling water, or of certain remedial agents, and particularly 
of tartar emetic, kermes mineral, or croton oil. These latter agents, 
the drugs just mentioned, cannot produce this effect unless used in large 
doses, or when continued for too long a time. The quantities of the 
antimonial preparations formerly administered, were always thought by 
us to be dangerously large, and we were not at all surprised to find that 
MM. Eilliet and Barthez, from their experience in former years in the 
Children's Hospital in Paris, cited them as one of the causes of acute 
gastritis. In the Journal fur Kinderkrankheiten, for the years 1859, 
1860, and 1861, in the third, fourth, and fifth annual reports of the 
Public Institute for Children's Diseases, of Vienna, by the Director, 
Dr. Luzsinsky, may be found in the third report three cases, in the 
fourth three cases, and in the fifth two cases of gastritis caused by the 
accidental drinking of concentrated lye. 

The milder forms of gastritis are vastly more common than the ones 
above referred to. Thej- are generall}- associated with disturbances of 
the intestinal tube also, and constitute by far the majority of the cases 
which come under the observation of the physician. They are caused 
very generally by improper alimentation ; by the same causes, indeed, 
as those which determine indigestion. In infants, an unhealthy state 
of the mother's or wet-nurse's milk, the use of too rich a preparation 
of cow's milk, milk obtained from an unhealthy cow, or a food com- 
posed of too large a proportion of farinaceous material, are the most 
common causes. In older children, an unwholesome meal, as a surfeit 
of cakes and candies, tough meats, unripe, or an excess of ripe fruits, 
the swallowing of a quantity of skins of grapes, of orange-peel, of the 
seeds of oranges, or such like imprudences or accidents, of all which 
we have seen examples, will sometimes occasion symptoms which we 



ANATOMICAL APPEARANCES. 379 

can refer only to acute catarrh of the stomach. In such cases the 
child may escape any serious consequences if it rejects, by vomiting, 
the improper food, soon after it has been taken. Or it may have an 
attack of cholera infantum or cholera morbus, and either recover its 
usual health in a short time, or pass through a longer or shorter illness, 
as the result of these disorders; or, lastly, the unhealthy food may be 
retained for a longer time than usual in the stomach, and acting as a 
local irritant on the gastric mucous membrane, may set up a true and 
more or less severe form of the disease we are considering. 

Anatomical Appearances. — Death is so rare a consequence of gas- 
tritis alone, except in the form produced by the direct application of 
irritants to the organ (and even in such, recovery appears to be the 
rule, since all the eight cases referred to as reported by Dr. Luzsinsky, 
recovered), that it is difficult to present a description of the lesions 
characteristic of this variety of the disease. M. Billard, however 
(M?/. des Enfants, p. 353), gives a case from M. Denis, and one observed 
by himself. M. Denis found the mucous membrane of a deep brown 
color, of a fetid odor, reduced here and there to a state of putrilage, 
and everywhere easily removed in softened strips. A fluid of the color 
of lees of wine, was found macerating the changed mucous membrane, 
and this he could ascribe only to gangrene fi'om excessive inflammatory 
action. The case observed by Billard occurred in a girl three days old, 
who was brought to the infirmary with a quantity of blackish blood 
passed into the napkins, and also vomited. The child died on the fol- 
lowing day. The mouth and oesophagus were healthy, but the mucous 
membrane of the stomach was completely destroyed, not far from the 
cardiac orifice, over a space as large as a thirty sous piece. The centre 
of this space was stained with blackish blood, and its edges, irregularly 
fringed, were blackened and looked as though they had been burned. 
Outside of this dark circle, the mucous membrane was thickened, of a 
violet-red color, and easily reduced to a pulp. The whole surface of 
the organ was lined with semifluid matters, of a bistre color, mixed 
with sanguinolent striae, and the mucous membrane beneath these 
matters was very thin and discolored, especially near the pylorus. 
The small intestine was stained yellow with bile, and contained frag- 
ments of coagulated blood. The large intestine was healthy. The 
liver was bloodless and pale; the spleen small and but slightly injected. 
No clue is given as to the cause of this grave lesion. 

The gastric lesions belonging to catarrh of that organ are very often 
met with, as we have already stated, but are almost always associated 
with changes in the intestinal mucous membrane. They are observed 
in severe indigestion, in simple and inflammatory diarrhoea, and in 
cholera infantum. For a full account of the histology of this lesion, 
we must refer the reader to the essay on Gastritis and Acute Gastric 
Catarrh, by Dr. Wilson Fox, in the System of Medicine, edited by Dr. J. 
Eussell Eeynolds. We shall, however, quote the shorter description 
given by Dr. Niemeyer (op. cit., vol. i, p. 476), of acute gastric catarrh. 
He says: '' We seldom have the opportunity of seeing the remains of 



880 GASTRITIS. 

acute gastric catarrh in post-mortem examinations; when we do, the 
gastric mucous membrane is found reddened in spots by a fine injection; 
its tissue is relaxed, and its surface covered with a layer of tough mu- 
cus. But more frequently, especially among children who die with the 
symptoms of cholera infantum, the autopsy gives negative results, ex- 
cept as to appearances which will be described hereafter. This does not 
appear strange when we remember that the capillary hypersemias of 
other mucous membranes, which we have been able to observe directly 
during life, leave no trace after death, and that a relaxation and partial 
loss of epithelium, which we have regarded as the most probable cause 
of the extensive transudation in cholera infantum, may be very readily 
overlooked in the dead body, and can very rarely be observed with 
certainty." 

The description of the anatomical appearances in gastritis will not be 
complete without some reference to a lesion which, some ten or twenty 
years since, was thought to be one of great importance in children. 
This lesion, known by the names of softening or gastro-malacia, was 
supposed by some to constitute a distinct pathological entity, and to be 
the result in most cases of inflammatory tissue-changes determined by 
many different causes. Even then, however, not a few observers be- 
lieved that the lesion was a post-mortem change, and not the conse- 
quence of changes caused by disease during life. This latter opinion 
has continually gained ground, until now it is generally believed that, 
when present in a marked degree, it is in fact a cadaveric change. 
Nicmeyer (op. cit., vol. i, p. 476) says that the gastro-malacia or soften- 
ing of the walls of the stomach, found on autopsy in children, is always 
a post-mortem appearance, and that "if a child dies who has had vom- 
iting and purging from abnormal fermentation in the stomach, and 
if there are still fermenting substances left there, the fermentation will 
not be arrested by the gradual cooling of the body. When the circula- 
tion ceases, the stomach can no longer resist the decomposition, which 
then extends to it also, just as the stomach that has been cut out of an 
animal and filled with milk, sofcens if left only for a short time in a 
warm place. Hence physicians who consider softening of the stomach 
as a post-mortem appearance, may also predict it with certainty when 
a child that has died of cholera infantum had eaten milk, or any other 
easily decomposed substance, shortly before death." 

That a certain degree and kind of softening does, however, attend 
upon catarrhal inflammation of the gastric mucous membrane, as a re- 
sult of faulty nutrition of the tissues during life, is probably quite as 
true as that the extensive white softening of one or more of the coats 
of the organ, not unfrequently met with, is the consequence of a post- 
mortem change. Thus Dr. Wilson Fox (loc. cit., p. 858) asserts, that 
the softening of the mucous membrane which accompanies acute ca- 
tarrh is totally distinct from the post-mortem softenings, which are 
distinguished by the transparency of the tissues. " It rarely exists," 
he says, "to any marked degree, except in extreme. cases, but there is 
always a certain diminution of resistance to the finger-nail or to the 



SYMPTOMS. 381 

scalpel, which materially assists, when conjoined with opacity and 
thickening, in distinguishing this condition. Louis's test of the extent 
to which it can be torn from the submucous tissue is a less available 
one, and applies rather to the states of post-mortem solution than to 
this condition." 

SY3IPT0MS. — It is very difficult to give an accurate account of the 
symptoms of inflammation of the stomach, for the following reasons: 
they have not as yet been studied with a sufficient degree of care; gas- 
tritis is, as was stated in the early portion of this article, rarely idio- 
pathic, but almost always a secondary affection in the course of other 
maladies; the symptoms which betray it resemble so closely those of 
intestinal diseases, as to make it very difficult, if not impossible, to draw 
a distinction between the two ; and lastly, in the great majority of cases, 
gastric complaints coexist with intestinal. 

The most important symptoms are vomiting, diarrhoea, loss of appe- 
tite, thirst, epigastric tenderness, sometimes tension of the abdomen, 
and slight febrile reaction. 

Vomiting is the most important of the different symptoms of gastritis. 
It is not, however, according to MM. Eilliet and Barthez, invariably 
present. It was observed by them particularly in cases following the 
administration of active remedies, while in those which occurred spon- 
taneously, it was much less common. It shows itself especially after 
the taking of food or drink. Sometimes when the stomach is empty, 
there is simply nausea and retching. In severe cases the vomiting is 
frequent, and accompanied by violent straining and pain. Diarrhoea 
exists in most cases, whether the attack be one of simple gastritis, or 
accompanied with enteritis. The appetite is generally lost or greatly 
diminished. Thirst is commonly acute, and often intense. The toiigue 
is described by some writers as being generally red, and sometimes 
smooth and glazed. The authors above quoted, state, on the contrary, 
that it presents nothing peculiar in most cases. It was generally moist, 
only slightly colored, covered with a white or yellow coat of variable 
thickness, and in some rare instances, red on the edges and tip, or gluey, 
or even dry and harsh. As a general rule, the abdomen is normal, ac- 
cording to the same authors, though in some cases there is more or less 
swelling and tension. According to most writers there is generally 
tenderness on pressure in the epigastrium. Infants and young children 
are commonly restless and uneasy, as though in more or less pain, while 
those who are older complain of burning in the region of the stomach. 
It is well to remark that MM. Eilliet and Barthez state that tenderness 
on pressure often exists, not at the epigastrium, but in one of the iliac 
fossae, or at the umbilicus^ even when the stomach alone is inflamed. 
The condition of the circulation, and indeed all the symptoms, depend 
so much upon the nature of the concomitant malady, that it is difficult 
to ascertain what are their real characters in simple gastritis. Most 
writers agree that fever usually accompanies the disease, and that it is 
commonly of the remittent type. It is certain, however, from other 
observations, that it is not always present. 



382 GASTRITIS. 

In very violent cases there are added to the symptoms just described, 
those indicative of an adynamic state of the nervous system : prostra- 
tion, cool or cold skin, with perspiration; weak, rapid pulse; singul- 
tus; sometimes convulsions, and death. The symptoms which have 
just been detailed as indicating the presence of gastritis, do not gener- 
ally exist alone. They are much more frequently than not associated 
with other symptoms, which show the presence of intestinal disease in 
the form either of simple or inflammatory diarrhoea. That they do 
sometimes, however, exist alone, and that, too, independently of the 
action of irritating drugs, or of coiTOsive poisons, we cannot ourselves 
doubt, since we have several times seen them follow attacks of simple 
indigestion. In such cases, we have met with all the symptoms usually 
supposed to indicate an inflamed state of the gastric raucous mem- 
brane, — repeated and obstinate vomiting, epigastric tenderness, entire 
loss of appetite, and more or less acute fever. We have, to be sure, 
never seen a post-mortem examination of such a case, for we have 
never yet known one to prove fatal. Whether we call such an attack 
gastritis, acute catarrh of the stomach, or emharras gastrique, matters 
not much. It is the condition which has long been looked upon as in- 
dicating an inflammatory state of the gastric raucous raembrane, and 
until we have more positive evidence than has yet been adduced, that 
inflammation has nothing to do with it, we shall deem it best to retain 
the old title. 

Diagnosis and Prognosis. — The diagnosis must rest chiefly on the 
existence and frequency of vomiting, on the j^resence of epigastric pain 
or tenderness, of swelling and tension of the abdomen and excessive 
thirst, and on the absence of other disease which might account for the 
illness of the child. 

The prognosis will depend on the severity of the gastric and consti- 
tutional symptoms, and on that of the concomitant disease, when the 
attack is secondary. When there is incessant and obstinate vomiting, 
so that not even water in small quantities can be retained after several 
hours of sickness, when the tongue is red and glazed, or dry and brown, 
and when adj-namic symptoms make their appearance, and emaciation 
makes rapid progress, it is much to be feared that extensive organic 
change has taken place, and that the case will prove fatal. 

Treatment. — The two most important points in the treatment are 
the withdrawal of the causes that may have produced, or may tend to 
keep up the disease, if these can be detected, and strict attention to 
diet. Whenever, therefore, the symptoms have made their appearance 
after the exhibition of powerful drugs, as tartar emetic, kermes mineral, 
or cathartics, their use ought to be instantly suspended. The child 
should be put on the strictest diet. If at the breast, it must be allowed 
to nurse only at rare intervals, and to take but little at a time. If fed 
on artificial diet, it should be restricted to barley- or arrowroot-water, 
to very weak milk and water, or to small quantities of milk diluted 
with lime-water, in the proportion of a third or a half of the latter. This 
is one of Dr. Chambers's favorite prescriptions, and is an admirable one. 



ENTERO-COLITIS. 383 

Nothing solid and no rich liquid nourishment onght to be allowed, unless 
the child is in a state of ^Yeakness and debility from previous or con- 
comitant disease, such as to make it absolutely necessary to endeavor 
to maintain its strength. Billard even recommends that the child be 
sustained by means of nutritive enemata, while the digestive function is 
allowed a total rest. 

Antiphlogistics are useful and proper when the disease occurs in a 
strong and healthy child, when it is associated with fever, and when 
there is nothing in the nature of the accompanying disease, if it be a 
secondary case, to prevent their employment. The most suitable mode 
of depletion is by leeches, which should be applied to the epigastrium. 
It is best to take but a very moderate quantity of blood, for fear of 
exhausting the patient. After the use of the antiphlogistic remedy, a 
warm bath will be found of great service in moderating the heat of the 
skin and rendering the child more comfortable. Small pieces of ice 
ought to be put into the mouth occasionally as a refrigerant, or small 
quantities of iced drinks may be allowed from time to time. As soon 
as the bleeding from the leech-bites, if leeches have been employed, has 
ceased, a warm light mush poultice to the epigastrium is a valuable and 
useful remedy. Some writers recommend the use of blisters to the epi- 
gastrium. We should much prefer a warm poultice or the occasional 
application of a mustard poultice. Opiates are useful in allaying nausea 
and vomiting, and appear to exert a favorable influence on the progress 
of the disease. 

When vomiting is frequent and troublesome, it may generally be 
allayed by the administration of lime-water and milk, given in tea- 
spoonful quantities every fifteen minutes or half hour; by observing 
the precaution of allowing the food and drink to be given only in the 
smallest quantities (from a teaspoonful to a tablespoonful) and at con- 
siderable intervals; by the application of warm cataplasms over the 
abdomen, or a spice-plaster to the epigastrium ; .or, lastly, by the exhi- 
bition of a few drops of laudanum or paregoric, to be repeated if neces- 
sary. If the child becomes weak and exhausted, with coolness and 
abundant moisture upon the limbs, we must resort to the administra- 
tion of some kind of stimulant. The best is weak brandy and water, 
given in very small quantities ; or we may employ wine-whey, or milk 
punch, or the aromatic spirit of hartshorn. 



ARTICLE IT. 

ENTERO-COLITIS OR INFLAMMATORY BIAREHCEA. 

Definition; Frequency.— By entero-colitis or inflammatory diar- 
rhoea, we mean that form of diarrhoea which presents, during life, in 
febrile reaction at some period of its course, in marked constitutional 
disturbances, and in the mucous, muco-purulent, or muco-sanguineous 



384 ENTERO-COLITIS. 

stools, the proofs of inflammatory changes in the intestinal mucous 
membrane; and which exhibits, after death, the tissue-changes in the 
small and large intestines which are regarded as the products of in- 
flammation of those organs. 

The disease is one of the most common and one of the most fatal of 
childhood. Few young children die in the foundling hospitals abroad, 
or in the hospitals and almshouses of this country, from insufficient 
or improper food, but die of this affection. Many, a large majority, 
we think, of the deaths accredited to cholera infantum belong to this 
disorder. The true choleraic disease is constantly passed through with 
safety, but is followed by a long, obstinate, exhausting diarrhoea, which 
is in truth an inflammatory diarrhoea occurring as a sequel to cholera. 

A large proportion of the cases of summer diarrhoea are, from the 
beginning, cases of this kind; or they commence as merely functional 
disturbances of the intestine, and run, sooner or later, into the disorder 
we are now considering. It is one of the most important diseases of 
young children, especially in this countrj^, where our long summer 
heats, and the filthy condition of many parts of some of our most 
famous cities, give it a degree of prevalence and fatality which raise it 
to the rank almost of a pestilence. 

We believe that most of the cases of diarrhoea in children, no matter 
what may have been the exciting cause at the start; whether a con- 
stantl^Mmproper diet, as in hand-fed children; whether ill-judged ex- 
periments in new foods by the mother or nurse; whether the accidental 
use of unwholesome food; whether summer heats, exposure to unhealthy 
and foul exhalations, crowding, malarial or epidemic causes, dentition, 
residence in cities, or what not, are prone to end, are nearly certain to 
end, if they become chronic, in this disease. This opinion is the result 
of our experience in private practice, in this city, during thirty years. 
It is curious, too, and it is confirmatory of the correctness of this opin- 
ion, that in our armies during the late war, diarrhoea, whenever it be- 
came chronic, exhibited lesions which are best indicated by the term 
entero-colitis, if we are to use a name based upon the anatomical lesions' 
of the disorder. 

Entero-colitis, then, is undoubtedlj', one of the most frequent of chil- 
dren's diseases, though it is impossible to determine accurately the mor- 
tality it occasions in this city, from the returns as at present made by 
our phj-sicians. 

Thus during the seven years (1862-1868 inclusive) there were 7273 
deaths under five years of age in this city, from the three diseases, 
cholera infantum, diarrhoea, and dysentery (not to include a compara- 
tively small number returned as due to colic, marasmus, inflammation 
of the stomach and bowels, aphthae, &c.). Of these, as will be seen by 
inspection of the accompanying table' (see p. 386), by far the greater 



1 We are indebted to the courtesy of Mr. Chambers, the clerk of the Board of 
Health in this city, for the opportunity of collating portions of this table from the 
monthly returns of mortality calculated by him. 



FREQUENCY — CAUSES. 385 

proportion, ijamely 5963, are recorded as due to cholera infantum. 
Our extended opportunities of observing the diseases of children in 
this city have, however, led us to the conviction already expressed in 
the remarks which preface this article, that the great majority of these 
cases should in reality be entitled entero-colitis, while the true choleraic 
disease, to which alone the term cholera infantum should be restricted, 
is a comparatively infrequent affection. 

We may appreciate yet more accurately the importance and fre- 
quency of the disease, by reference to the statements of MM. Eilliet 
and Barthez, who say (lere edit., t. i, p. 483), that, taking into consid- 
eration all the cases they observed, including tubercular cases^ they 
find that of every two children that die, one presents a more or less 
serious lesion of the large intestine. Thej' add: "If it be recollected 
that this holds true particularly in regard to younger children, it will 
be seen that it is rare for a child to die between two and five years of 
age, without having either colitis or softening of the large intestine." 
Bouchut states that entero-colitis is one of the most dangerous affec- 
tions of children at the breast: "It is the most common of all those in- 
cident to that age" (p. 210). 

We shall describe two forms of the disease, the acute and chronic. 
The acute form is accompanied by active and inflammatory symptoms 
from the first, and runs its course in a few days or weeks; the chronic 
form is unaccompanied by acute symptoms, and lasts several weeks or 
months. 

Causes. — The two most important causes of this disease amongst 
us, are improper alimentation and the heats of summer. The im- 
proper alimentation consists in an unhealthy state of the nurse's milk, 
or, what is much more common, of some improper kind of artificial 
nutriment; of the latter, the kind of food most apt to produce the 
effect, is one composed exclusively or in considerable proportion of 
some of the feculent substances^ which constitute so large a portion of 
the diet of children throughout the civilized world. To prove the 
truth of this assertion it is only necessary to quote the opinions of 
those who have most carefully studied the subject. M. Valleix {Guide 
du Med. Frat., t. iv, p. 60, 61, and Bulletin Gen. de Therap., article Acute 
Enteritis of Adults and New-born Children, March, 1845), clearly asserts 
that the most frequent cause of muguet, which he believes to be essen- 
tially connected with enteritis, is a too exclusively feculent alimenta- 
tion. In the article last cited, while speaking of the great importance 
of this cause, he says: "What proves that my assertion is not hypo- 
thetical is, first, that all the deaths from enteritis in children that I 
have seen occurred in those who had been placed upon this kind of 
regimen, and second, that the disease did not occur in any of those 
observed by me in private practice, for whom I had directed an exclu- 
sively milk diet up to four, five, or six months of age." He adds that 
M. Trousseau had arrived at similar opinions, after studjn'ng the same 
diseases at the decker Hospital; and that he, on account of the danger 

25 



886 
Table 


ENTERO-COLITIS. 

SHOWING THE Monthly Mortality for the last Seyex Years rRo:M 
Years of Life; compared with the Total Monthly Mortality 


Month. 


1862. 


! 1863. 

i 


1864. 


1865. 1 


Mortality. 




MOBTALITY. 

1 


t 

il 


Mortality. 


6 


Mortality. 


i 


Cholera 
Infant. 
Dysent. 
Diarrh. 


Total. 


Cholera 
1 Infant. 
Dvsent. 
Diarrh. 


Total. 


Cholera 
Infant. 
Dvsent. 
Diarrh. 


Total. 


Cholera 
Infant. 
Dysent. 
Diarrh. 


Total. 

1 


Jan. 


1 
2 

4 


1314 


32.46° 



3 
3 


1061 


S8.25° 


1 


5 


1302 


33.28° 


1 
6 
3 


1373 


26.78° 


Feb., 


1 


1080 


32.70° 


5 
3 
2 


1122 


35° 



3 



i 
1434 35.97° 

1 


2 
2 
1 


1550 


32.59° 


March, 


I 

3 


1204 


40.25° 



2 

7 

[ 


1172 


37.26° 


4 

1 
5 


1894 


40.5° 


3 

1 
2 


1868 


47.94° 


April, 


3 
1 
4 


1213 


50.61° 


2 
5 
6 


1488 


49.80° 


2 
2 
6 


1377 


50.58° 


5 
3 
4 


1411 


56.46° 


May, 


9 
4 
5 


1343 


63.70° 


5! 

1 1060 

6 i 


64.63° 


10 

5 

8 


1529 


67.20° 


10 
6 

7 


1227 


63.39° 


June, 


20 
3 
8 


1002 


69.14° 


14 
2 
5 


961 


68.76° 


74 
11 
14 


1245 


72° 


184 
10 
20 


1690 


76.73° 


July, 


300 
21 
31 


1767 


75.23° 


313 
17 

38 


1859 


77.07° 


259 
24 
32 


1643 


76.08° 


364 

52 
41 


1838 


77.82° 


Aug., 


217 
19 
22 


1755 


76.70° 


464 
25 

28 


2044 


79.46° 


250 
27 
31 


1956 


79.40° 


245 
42 
23 


1759 


74.74° 


Sept., 


60 
4 
9 


1037 


69.36° 


105 

15 

9 


1453 


64.73° 


28 
16 
10 


1251 


65. 


44 
14 

7 


1040 


72.68° 


Oct., 


15 
5 
4 


1235 


58.32° 


14 
4 
5 


1104 


56.08° 


9 
8 
4 


1144 


54.75° 


15 

12 

5 


1084 


54.88° 


Nov., 



2 
6 


1021 


45.20° 


5 


1 


1061 


47.72° 


2 
2 
1 


1212 


45.80° 


9 
8 
3 


1285 


45.35° 


Dec, 




1 
2 


1124 


36.06° 


3 

2 
1 


1404 


35.41° 


2 
2 
4 


1595 


36.77° 




2 
3 


1044 


37.39° ^ 


Total, 803 






1120 






862 






1139 

































FREQUENCY — INFLUENCE OF SEASON AND TEMPERATURE. 387 



Cholera Ixfaxtum, Dysexteey, a:n'd Diaerhcea, during the First Five 
FROM ALL Causes, and the Mean Monthly Temperature. 



1866. 


1867. 


1868. 


O 5 c3 

111 

oil a> 


is" 


g 
> 

is 

a 

0) 


1 r^rOKTALITV. 




Mortality. 




MOETALITY. 




-'ni.. Total. 


A 


ICholera 
Infant. 
Dysent. 
Diarrb. 


Total. 


jCholera 
Infant. 
Dysent. 
Diarrh. 


Total. 




1 1402 ; 29.81° 

^i 1 


3 

4 


1376 


25.89° 


2 
2 

1 


1249 


30.12° 


7t 

2 

3f 


1296f 


30.87° 


1 i 1 " 

2 1156 ! 34.14° 

^1 ! 


3 
2 
3 


1042 


40.21° 







1063 


26.65° 


U 
2i 
l' 


r206f 


33.89° 


^\ i- 

1082 '40.85° 

3 1 


3 
1 
2 


1094 


38° 


1 
1 
1 


1096 


41.12° 


22 

4 

3f- 


13442 


40 85° 


6 , 1 

3 1034 '56.06° 

4 1 

i ' 


I 




1088 


54.13° 


9 
5 

2 


1357 


48.24° 


4 

3 


1281| 


52.27° 


8i 1 i 
1 ' 1304 i61.37° 

4 ' \ 


1 7 
2 
3 


1260 


59.44° 


4 

I 


917 


59.66° 


7f 
2f- 
4f 


12342 


62.77° 


68 

2 

10 


1168 


73.04° 


38 

6 
5 


980 


72.19° 


71 

8 

7 


1201 


71.99° 


67 
6 


1178f 


71.97° 


■; 427 
=f 21 
i 34 


2047 


80.37° 


423 

23 
31 


1795 


76.48° 


423 
14 
32 


1900 


80.94° 


3584 

244 
34} 


1837 


77.71° 


366 

36 

! 41 


2401 


72.5° 


265 
26 
25 


1294 


75.10° 


327 
19 
34 


1570 


78.42° 


304f 
274 
29^ 


1825f 


76.62° 


.' 89 

'^ 15 

13 


1362 


69.42° 


88 

13 

9 


1012 


68.21° 


128 
14 
24 


1353 


68.80° 


77f 
13 
11 f 


1215f 


68.31° 


56 

3 

15 


1828 


58.35° 


24 



10 


1177 


57.65° 


20 
2 
3 


955 


54.08° 


152 

U 
4 


12181 


56.3^ 


6 

4 


1037 


48° 


6 
2 
5 


871 


47.79° 


3 
2 



878 


46.91° 


31 

2f 


1052^ 


46.68° 


2 
2 

3 


982 


33.63° 


1 
2 

2 


974 


31.78° 


1 

3 


1154 


32.16° 


9 

^1 


1191 


34.7° 


1252 






1040 






1057 





































388 ENTERO-COLITIS. 

of a system of diet disproportioned to the digestive powers, recom- 
mended that children be confined almost exclusively to the breast until 
after the first dentition is completed. Barrier, speaking of the fol- 
licular diacrisis {op. cit., t. ii, p. 40), states that the artificial food given 
to children at the period of weaning is a frequent cause of the affec- 
tion, and that of all the different kinds of food habitually employed at 
that period, feculent substances are the most injurious. We have 
frequently known entero-colitis to follow the employment of artificial 
diet, either alone, at the period of weaning, or in children who were 
partly nursed. Children fed wholly on artificial diet from birth, 
rarely escape, according to our experience, attacks of the disease, 
which in man}' prove fatal. AVe have, on several occasions, seen chil- 
dren recover rapidly from such attacks, after suffering more or less for 
weeks, by the suspension of a diet consisting wholly or in too large 
proportion of farinaceous materials, and the substitution of one com- 
posed of milk and cream, prepared with gelatin, and containing a 
very small quantity of arrowroot, rice, or wheat flour (see article on 
thrush, page 338). It is not merely the quality, but the quantity also 
of artificial food that proves injurious to infants. Overfeeding has 
always been recognized as a fruitful source of bowel complaints in 
early life. Another cause is the preparation of the food in too thick 
and rich a manner, thereby overtasking the stomach, intended during 
the early months to receive only the thin milk supplied by nature. 
The custom, therefore, of feeding infants on thick oatmeal gruel, with 
but little or no milk, on what is called cracker victuals (pounded 
crackers w^ith water and sugar, or milk), on thick bread and milk, on 
preparations of rice of too solid a nature, or indeed, on any kind of 
diet not consisting chiefly of milk, and in which feculent substances 
enter merely as secondary constituents, may safely be asserted to be 
the most frequent cause of the disease under consideration. 

An unhealthy character of the milk of the nurse is also known to be 
a cause both of simple diarrhoea and entero-colitis. When the granule 
cells which exist as a phj'siological element in the colostrum secreted 
during the first few days after childbirth, continue to be present after 
that period, the infant is almost certain to suffer from entero-colitis, 
and not unfrequently to die, unless weaned or transferred to another 
nurse. So, also, when the milk departs widely from the normal char- 
acters which it should possess, as described at page 340; when the 
nurse is liable to vivid moral emotions of any kind, or when addicted 
to intemperance; the child is very apt to suffer either from the disease 
under consideration, or from simple diarrhoea. 

That the heats of summer are a most fruitful cause of this disease, no 
one can doubt who will glance at the table given at pages 386 and 387, 
where the mortality from cholera infantum, dysentery, and diarrhoea, 
under five 3'ears of age, in this city, during the seven years from 1862 
to 1868 inclusive, is given. 

The table shows at a glance, the number of deaths from these dis- 



CAUSES. 389 

eases enumerated, during the period of life specified, in each month of 
every year, with the mean temperature of each month, and also the 
total mortality at all ages and from all causes in each year. The 
reader must not forget what we have already stated, that there is 
every reason to suppose that a large majorit}^ of the cases reported 
nnder the head of cholera infantum are, in fact, cases of entero-colitis, 
— at least what we have proposed to call entero-colitis, as opposed to 
the less frequent choleraic disease to w^hich we restrict the term cholera 
infantum. It will be seen, in this table, that the two months of July 
and August furnish by far the largest proportion of deaths. In these 
two months, when the mean temperature is noted between 70° and 80° 
Fahr., the deaths from this disease ran up to three and four hundred 
and upwards; whilst in June and Septem^ber, when the temperature 
ranges between 60° and 70°, the deaths average between 60 and 80, 
and rarely rise over 100; and in January and Deceniber, with a tem- 
perature of from 30^^ to 40°, they number from between 3 and 5 to 10 
and 15. The effect of season is here so striking that it must interest 
all, and can leave no doubt, we think, in the mind of the reader, but 
that the elevated temperature of summer is the main cause, in this city, 
of the fatal intestinal disease we are considerina:. Whether heat alone 
may act upon the system of the child to produce this result, or whether 
it acts always by determining noxious gaseous products from the de- 
composition of animal and vegetable substances thrown into our streets, 
has not yet been demonstrated. From the well-known fact, however, 
that those children suffer most w^ho reside in the more filthy and 
crowded part of the city, whilst the disease is very much less common 
in the open country, and in the cleaner and better ventilated parts of 
the city, we may safely conclude that it is not heat alone that usually 
causes the disease, but that the emanations arising from garbage of 
various kinds, and the- imperfect ventilation of houses built in narrow 
and crowded streets, have much to do in its causation. 

We referred, in the general remarks at the beginning of this chap- 
ter, to the resemblance of the chronic diarrhoea of our armies during 
the late great war, in its mode of causation, symptoms, anatomical 
lesions, and the effects of treatment, to the chronic form of entero-colitis 
in childhood. 

Any one who will refer to the work of Dr. Woodward, already quoted, 
or to the essay on Caynp DiarrhoRa and Dysentery^ by Dr. S. B. Hunt, in 
the United States Sanitary Commission Contributions relating to the Causa- 
tion and Prevention of Disease, and to Camp Diseases, &c. (New York, 
1867); or to the Investigations upon the Diseases of the Federal Prisoners 
confined in Camp Siimjpter, Andersonville, &c., by Joseph Jones, M.D., pub- 
lished in the volume just alluded to ; will find ample proof that improper 
diet, with heat, overcrowding, and want of cleanliness, will give rise to 
chronic diarrhoea, the essential lesions of which are to be found in 
radical blood-changes, perverted nutrition, and a localization on the 
alimentary canal in the form of entero-colitis, very much like the dis- 
order we are describing. Dr. Woodward says, in fact, in speaking of 



390 ENTERO-COLITIS. 

the nature of this affection (chronic diarrhoea), at page 251: "From 
the account given above of the pathological anatomj' of the disease, 
there can be little doubt that this affection is to be regarded as consist- 
ing essentially of a chronic inflammatory process, involving primarily 
the mucous membrane of the ileum and colon. It may, in fact, be de- 
scribed simply as a chronic ileo-colitis, with a tendency to ulceration." 
Dr. Hunt (loc. cit., p. 29-i) says: ^'The essential fact in the pathology 
of all these various forms of flux is the same, and autopsies reveal no 
distinction between cases of diarrhoea and dysentery. They are alike 
an inflammation of the colon or of the smallintestine.or of both, attended 
by ulceration of the mucous membrane. The solitary follicles of the 
colon are seen to be enlarged simply, or ruptured, with punched-out 
ulcerations following. The intestinal wall is thickened and changed 
in color to a red, brown, black, or greenish hue." 

It may seem, at first view, visionary and wild to compare the chronic 
entero-colitis or inflammatory diarrhoea of childhood to the same dis- 
order in armies and camps; and yet we think there is a most striking 
analogy between the two as to causation, symptoms, anatomical lesions, 
pathology, and the results of treatment. The main causes are the 
same: improper diet; elevated temperatures, the high temptrature of 
the summer season in children, and of the Southern States in the 
armies; overcrowding, with foul air in camps and cities: the symptoms 
are very much alike, a most obstinate diarrhoea, with great constitu- 
tional suffering and emaciation ; the same lesions are present, only less 
advanced and extensive in most cases of children ; and very much the 
same results follow treatment : as in both diet is found to be more im- 
portant than drugs, and removal North in the armies, and in children 
removal from crowded cities or low hot regions of the country to more 
elevated and cooler tracts, are found necessar3\ In childi-en, as in 
armies, if, at the beginning of the attack, the patient is removed from 
the causes which have produced a simple diarrhoea or a cholera infan- 
tum, the case is likely to go no further; but, if the same causes are 
continued in operation, the simple diarrhoea passes gradually into the 
chronic inflammatory form of entero-colitis, and at last the patient re- 
covers only when he is removed to a more favorable locality, when the 
diet is changed to a more healthy one, or, in the child, when he drags 
through a long hot summer, and the cooler weather of October or No- 
vember, and a diminution of the exhalations caused by the summer 
heats in cities, bring at last, in the course of nature, the change which 
was essential to his recovery. 

After the causes just enumerated, the one which appears to exert the 
strongest influence is dentition. That the evolution of the teeth, though 
a physiological process, is a powerful predisposing cause of diarrhoea 
and enteritis, cannot be doubted at the present time. It is one recog- 
nized by many of the most able writers and observers of the day, and 
by most practitioners. MM. Rilliet and Barthez agree with Trousseau 
in the opinion that the simple diarrhoea so apt to occur in children at 
the epoch of the first dentition, is often the origin of chronic intestinal 



CAUSES — MORBID ANATOMY. 391 

lesions which finally reduce them to extreme debility and emaciation. 
They say that careful investigation will generality show that nearly all 
the cases of inflammation and softening date either from the epoch of 
dentition, from the period of weaning, or from the time at which some 
considerable change in the character of the regimen was made. M. Bou- 
chut states that of 110 children in whom the first dentition was going 
on, 26 escaped any indisposition, 38 suffered from restlessness, colics, 
and occasional diarrhoea, so mild as to excite no alarm in the parents, 
whilst 46 had abundant diarrhoea. In 19 of the last series it appeared 
coincidently with the fluxion of the gums, occurring at the time of 
emergence of each tooth, and disappearing entirely in the intervals; in 
the remaining 27, in all of w'hich the process of dentition was difficult, 
the diarrhoea persisted and gradually assumed the characters of entero- 
colitis. M. Legendre and M. Barrier (loc. cit.) both agree in ascribing 
very great effect to the influence of dentition in the production of diar- 
rhoea and entero-colitis. The former asserts the diseases referred to to 
be much the most frequent between the ages of six or seven months 
and two or two and a half years, which includes exactly the period oc- 
cupied in the first dentition, w4iile they are only met with exception- 
ally after three years of age. 

The act of weaning is very apt to result in the production either of 
simple diarrhoea or entero-colitis, in consequence, no doubt, of the irri- 
tation set up in the gastro-intestinal surface, by the change of food 
made at the time. The diarrhoea which occurs at this period was for- 
merly, and is still, not unfrequently, called weaning -brash. Dr. Stokes 
(^Cyclop, of Med., Art. Enteritis) says of this disease tliat it "is mani- 
festly an acute enteritis, produced by the change of food, and in which 
nature seeks to relieve the inflammation by a supersecretion." 

Entero-colitis is prone to occur as a secondary affection in many of 
the acute diseases of children. It is by far the most common in the 
course of the eruptive fevers, particularly measles, and in that of ty- 
phoid fever. It is also a frequent complication of the latter stages of 
pneumonia. 

That children of feeble constitution and lymphatic temperament are 
more disposed to the disease than others, is sufficiently proved by the 
evidence of various observers. Lastly, that the incautious and exces- 
sive use of perturbing systems of medication, addressed to the digestive 
tube, often occasions diarrhoea and entero-colitis, is fully proved by the 
researches of MM. Eilliet and Barthez, and by our own experience. 

Morbid Anatomy. — Seat oe Disease. — It has been already stated, 
that the alterations of the large intestine are, as a rule^ much more fre- 
quent and serious than those of the small intestine. It appears from 
the researches of MM. Eilliet and Barthez, and Legendre, that enteritis 
rarely exists alone; whilst colitis by itself, or combined with enteritis, 
is quite frequent. M. Legendre states that inflammation of the small 
intestines never occurs without corresponding lesions of the large 
bowel, w^hile in 28 cases of diarrhoea, he found the large intestine alone 
diseased in 9. From a table of different intestinal lesions, given by 



392 ENTERO COLITIS. 

Eilliet and Barthez (op. cH., t. i, p. 692), it appears that they have met 
with 45 cases of erythematous, pseudo-membranous, ulcerative or pus- 
tular enteritis; with 113 of the same forms of colitis; with 90 of fol- 
licular enteritis; 64 of follicular colitis; and with 28 of softening of the 
small, and 85 of softening of the large intestine. Dr. J. Lewis Smith 
(op. cit., p. 367), offers an analysis of the postmortem appearances in 
82 cases of intestinal inflammation in children. The upper part of the 
small intestine, embracing the duodenum and jejunum, was found in- 
flamed in 12 cases, while in 51 cases it was free from inflammation and 
of a pale color. The ileum was inflamed in 49 cases, and the esecal por- 
tion, including the ileo-C8ecal valve, was the part in which the inflam- 
mation was uniformly most intense, and to which it was often conflned; 
in 13 cases there was no enteritis whatever, and in 16 there was no in- 
flammation of the ileum, so that the ileum was inflamed in all but 3 
cases where enteritis was present. On the other hand, in all the cases 
excepting one, namely, in 81 out of 82 cases, there were lesions indi- 
cating inflammation of the mucous membrane of the colon. In 39 the 
inflammation had affected nearly or quite the entire extent of this por- 
tion of the intestine ; in 14 it was confined to the descending portion 
entirely, or almost entirelj^; in 28 cases, the records state that colitis 
was present, but its exact location is not mentioned. 

We may add, that, in the quite numerous autopsies we have made 
after death from this disease, we have invariably found the large intes- 
tine involved, the inflammatory lesions being in some cases limited to 
it, while in others they also extended into the small intestine. 

It is, therefore, clearly established, that in the inflammatory diarrhoea 
of children, inflammation of the large is considerably more frequent 
than that of the small intestine, and much more apt to exist alone. 
The lower end of the ileum is the portion of the small intestine which 
presents the most advanced and severe lesions; while in the large in- 
testine the lesions are most marked in the caput coli, sigmoid flexure, 
and descending colon. 

In our description of the lesions of entero-colitis, we shall divide them 
into those found in the acute and chronic forms of the disease respec- 
tively; a division made for the sake of correspondence with the descrip- 
tion of the symptoms, although the lesions found in the two stages differ 
from each other only in extent and degree. 

Thus, in the acute stage, the lesions consist of increased vascularity, 
thickening and softening of the mucous membrane of the intestine, and 
enlargement of the intestinal follicles; while in the chronic form there 
is discoloration, thickening, with infiltration and induration of the walls 
of the intestine, and more or less extensive destruction of the mucous 
membrane from follicular ulceration. 

In the acute stage, the increased vascularity (inflammatory hyper- 
semia) may present itself as a uniform, more or less intense redness of the 
mucous membrane; an appearance which may sometimes exist in the 
duodenum, but far more frequently is observed in the lower end of the 
ileum and in the colon. More frequently it takes the form of arbores- 



MORBID ANATOMY. 393 

cent congestion, occurring in patches surrounding the enlarged follicles. 
The peritoneal surface mfxj also be more or less vascular, and quite fre- 
quently there are little patches of redness and arborescent vascularity, 
coiTesponding to the bases of the inflamed mucous follicles. 

The thickening of the mucous membrane usually corresponds to the 
degree of vascularity, and when the latter is but slight, maybe scarcely 
appreciable ; while in other cases, and especially when associated with 
much enlargement of the mucous follicles and oedema of the submucous 
tissue, the thickening is highly marked. The inflamed portions of the 
mucous membrane are also more or less softened, so that they can be 
detached from the subjacent coats more readily than in health. In 
some instances the softening is so extreme that it is impossible to raise 
up the mucous membrane in strips at all. These lesions are all most 
frequent and marked in the lower part of the ileum, and in the descend- 
ing part of the colon. In addition to these changes in the color, thick- 
ness, and consistence of the mucous membrane, the mucous follicles are 
prominently enlarged. In the normal state, the isolated follicles of the 
mucous membrane of the intestine, in young children, appear as minute 
grayish-white bodies, and present a grayish point, the excretory orifice, 
which is only visible with the aid of a lens. In the course of entero- 
colitis, however, the morbid development which they undergo causes 
them to present the following characters. The isolated glands are en- 
larged, and seem, therefore, more numerous than in the healthy condi- 
tion ; they appear in the form of lenticular grains seated in the texture 
of the mucous membrane, sometimes projecting from its surface, some- 
times not, and in other instances appearing to be situated beneath it; 
the excretory orifices of the follicles are often enlarged and tumid, and 
easily distinguished under the form of a grayish or blackish point in 
the middle of the gland ; in other cases the orifices cannot be distin- 
guished until slight pressure is made upon the crypts, when a drop of 
turbid mucus may be seen exuding through the open point. The color 
of the distended follicles is dull white, rosy, or yellowish ; they are 
generally from one-third to two-thirds of a line in diameter. Dr. 
Horner (^Amer. Jour. Med. Sci., Feb. 1829) speaks of them, in this state 
of development, as resembling " small grains of white sand sprinkled 
over the mucous membrane, and about the size of a millet-seed.'' 

The agminated glands or patches of Peyer are found in the same 
state of increased development; they are tumefied, and project above 
the level of the surrounding mucous membrane, and the orifices of the 
follicles are congested, so as to appear as dark points, giving to the 
patch a dotted, punctated appearance, which has been compared to the 
freshly-shaven chin. 

A little later the enlarged follicles present minute, oval, or round 
yellowish spots upon their summits, which soften down and allow the 
contents of the follicles to be discharged. The enlarged orifice of the 
follicle will then admit a small probe, and may even measure one-half 
a line in diameter. It leads into a little cavity, which is the follicular 
sac. The mucous membrane which overhangs this cavity like a fringe, 



394 ENTERO-COLITIS. 

is thus undermined and partly cut off from its vascular supply, so that 
we may find a process of ulceration advancing in it until the base of 
the distended follicle is exposed, appearing as a small; oval, or round 
shallow ulcer. 

These various conditions of the follicles may all be seen at the same 
time in a single portion of intestine. The enlarged patches of Peyer 
often have the appearance of being ulcerated, but a careful examina- 
tion will generally show that this is not the case. The appearance de- 
pends upon the enlargement of the orifices of the glands, upon unequal 
tumefaction of the surrounding mucous membrane, and upon the pres- 
ence, in the patch, of small, irregular graj^ish points, consisting of pul- 
taceous matter, which makes the patch look more uneven and projecting 
than usual. If, however, the pultaceous layer be gently rubbed with a 
piece of linen, it can easily be detached, when the mucous membrane 
beneath is found red, softened, and thickened, but not ulcerated. In 
comparatively^ rare cases, however, there are superficial erosions of the 
mucous membrane, covering the prominent patch. 

The exact date at which the ulceration of the follicles begins, is as 
yet undetermined, and probably varies greatly in difierent cases. It 
frequently happens, however, that death occurs, especially from tiie 
supervention of a choleraic condition, whilst they are still merely in a 
state of enlargement. "When, on the other hand, the disease passes 
into the chronic form, the lesions which we have above described be- 
come more and more extensive. This is especially the case with the 
lesions of the large intestine, for it is even more true with regard to 
chronic than acute entero-colitis, that the chief seat of the disease is in 
the colon. 

In chronic entero-colitis, the intestine is often contracted, and the 
peritoneal surface may present patches of discoloration. The thicken- 
ing and infiltration have 'now afi'ected the submucous and muscular 
coats, and have been followed by induration of the tissues, so that the 
walls of the intestine are often abnormally rigid. This is especially 
true with regard to the lower part of the descending colon and the 
rectum. The mucous membrane is seen to be riddled, not with mere 
superficial erosions, but with true ulcers, aff'ecting the w^hole thickness 
of the membrane. These ulcers, when isolated, are from one to one 
and a half lines in diameter, oval or circular in shape, and either have 
sharp-cut edges, as though the piece of mucous membrane had been 
cut out with a punch, or the mucous membrane bounding them is un- 
dermined.' Frequently, however, these ulcers coalesce, and at the same 
time extend in depth, so that large, sinuous, irregular ulcers are 
formed, with thickened, slate-gray, undermined edges, and having for 
their base either the submucous or muscular coats^ which may be cov- 
ered with a pultaceous, apparently pseudo- membranous layer, of a 
graj'ish-white color. These ulcers surround and include irregular islets 
of mucous membrane, which are swollen, infiltrated, vascular, and dis- 
colored. That the large and deep ulcerations just described, even when 
most extensive, take their start from the mucous follicles, is x^roved by 



MORBID ANATOMY. 395 

the frequent presence amongst them of other ulcerations of more recent 
date and smaller size, which present all the characters of the follicular 
ulcer, and show clearly the origin of the larger and more advanced 
ulcerations. Occasionally there is a marked deposit of pigment in the 
bases of the ulcers, and in some cases small coagula of blood have 
been found adherent to their bases. 

We have already had occasion to allude to the marked analogy be- 
tween the disease under consideration, and the form of camp diarrhoea 
described by \Yoodward (op. cif.) ; and one of the most powerful argu- 
ments in favor of the essential identity of the two affections, is the per- 
fect correspondence between their anatomical lesions. We present be- 
low a summary of the microscopical changes in the intestine during the 
development of these lesions, as determined by the careful investigations 
of Dr. Woodward (op. cit., p. 246). In the early stage, attended merely 
with thickening and softening of the mucous membrane, microscopic 
examination shows marked multiplication of the connective-tissue cells 
about the base of the follicles, and soon the tissue is occupied by great 
groups of small, rounded, or slightly polygonal cells. The delicate 
layer of muscular tissue immediately beneath the base of the follicles, 
presents, at first, enlargement and proliferation of its nuclei, whilst 
later it often ceases to be recognizable, being obscured by the luxuri- 
ant cell-growth. In the most intense cases, the cell-growth here de- 
scribed as attained toward the surface of the membrane, may take place 
throughout its whole thickness, and even involve the subjacent muscu- 
lar layer. 

A similar proliferation takes place in the connective tissue, which lies 
between the follicles. The epithelial layer, whi^h invests the mucous 
membrane, and is prolonged into the tubular follicles, either is the 
seat of rapid cell multiplication, or is exfoliated and replaced by round 
granular cells from the adjacent connective-tissue cells. The epi- 
thelial lining, near the orifice of the follicles, appears to undergo these 
changes most readily and with the greatest rapidity. 

The closed follicles also present rapid cell multiplication, which af- 
fects the parenchyma of the follicle, as well as the connective tissue of 
its capsule and the surrounding cellular tissue. Microscopic examina- 
tion then shows the follicle distended with small, rounded, granular 
cells, and imbedded in a luxuriant growth of similar cells, which ren- 
der it almost or quite impossible to draw the line where the follicle 
terminates and the surrounding connective tissue begins. "Ulcei-ation 
usually appears to originate in the rupture of one of the closed follicles, 
and the discharge of its softened contents into the intestinal cavity. 
This is followed by the liquefaction of the intercellular substance, and 
the consequent liberation of the broods of minute cells, into which 
the surrounding connective tissue has been transformed. Hence re- 
sults one of the punched-out ulcers described above. In the subsequent 
extension of the ulceration, by which large, irregular, sinuous ulcers 
are produced, the progress seems to take place chiefly in the submucous 
connective tissue, the superficial part of the mucous membrane resist- 



396 ENTERO-COLITIS. 

ing the process until UDdermined, and its nutritive supply cut off. 
Hence arises the excavated undermining character of the edges of the 
ulcers. From the anatomical point of view, it will therefore be per- 
ceived that the morbid process, in the cases in which there is no ulcer- 
ation, is essentially the same as in those in which ulceration is present. 
The one lesion is only a later stage of the other." 

^ot unfrequently there will be found one or more intussusceptions of 
the ileum. These are usually readily restored, and have evidently oc- 
curred during the act of dying. Smith has, however, "in a few in- 
stances, found intussusceptions, which sustained the weight of two feet 
or more of intestine, without being reduced, and which, from being in 
their interior more vascular than the contiguous membrane, had prob- 
ably occurred some hours or days before death, but being sufiSciently 
pervious to allow the food to pass, the symptoms of obstruction were 
lacking." 

The Mesenteric and MesocoUc Glands are nearly always enlarged, the 
most marked enlargement corresponding to the lower end of the ileum 
and the descending colon. The enlarged glands are of a pink color, 
and rather more soft and succulent than normal. 

Stomach. — In the great majority of cases the stomach is quite health}' ; 
in a few instances, however, there may be found congestion of the mu- 
cous membrane, slight enlargement of the mucous follicles, or softening 
of the mucous membrane, probably cadaveric in most cases. 

Liver. — Many authorities, apparently led by the presence of sj^mp- 
toms supposed to indicate disturbance of the function of the liver, have 
assumed that there is in most cases of entero-colitis some morbid 
condition of this organ, but extended observation has disproved this 
view. 

Thus Hallowell (^Amer. Joiirn. Med. Sci., July, 1847) found, that in 14 
cases, the liver was affected in but 1 case, when it was enlarged ; and 
Smith (op. cit., p. 370) has published the result of 32 post-mortem ex- 
aminations in regard to this point, which confirm the same conclusion. 
Thus, he states, "there was no evidence from the post-mortem appear- 
ances of the liver in these cases of any congestion, or torpidity, or hy- 
peractivity, or perverted secretion. The size of the liver was in some 
cases ver}'- different in those of about the same age, but probably there 
was no greater difference than usually obtains among glandular or- 
gans within the limits of health. In most of the cases the liver was 
examined microscopically, and the only fact worthy of note observed 
was the variable amount of fatty matter. Sometimes it Avas in excess, 
sometimes in moderate quantity or rather deficient, and sometimes in 
greater amount in one portion of the organ than in another." 

The thoracic viscera present no constant or important lesion, though 
in a certain proportion of cases, there may be found more or less h3^po- 
static bronchitis with collapse of portions of the lungs. 

When death occurs during the acute stage, the brain presents no 
lesions dependent upon the disease. When the case has been protracted 
and attended with much wasting of the solids and fluids of the body, 



PATHOLOGY. 397 

the brain also diminishes in size, and there is frequently found marked 
excess of subarachnoid effusion in cases where the fontanelies have 
closed: while if these spaces still remain unossified the}^ become 
markedly depressed. These appearances are, however, purely passive 
in their character, and depend upon the wasting of the brain. 

Pathology. — The pathology of inflammatory diarrhoea is involved in 
great obscurity. We are now pretty well acquainted with the physi- 
cal conditions under which the disorder is most apt to be developed. 
Early age, the period of dentition, high temperatures, improper food, 
residence in cities, and especially the crowded occupation of small and 
ill-vcDtilated buildings, in narrow courts and alleys, where unhealthy 
exhalations arise from the decomposition of filth and dirt of all kinds, 
are the chief conditions which precede the outbreak of the disease. 
But how these conditions act to produce their effect is still a matter of 
doubt. To attempt to reason upon a matter so full of difficulty seems 
almost useless, and yet we shall venture to place before the reader 
some thoughts we have had upon the subject. 

There are two broad generalizations which we think may be safely 
assumed to be true. 1. An unhealthy food, one incompetent to furnish 
to the body what it needs for the purposes of nutrition, as farinaceous 
food or unhealthy milk, is sure to produce the disorder we are consider- 
ing, no matter how favorable may be the circumstances, in all other re- 
spects, in which the child is placed. 2. The best breast-milk in the 
world, or the most correct artificial diet, will not save a' child from this 
disorder who is located in an ill-ventilated house in a dirty and filthy 
quarter of a large city during hot weather. Here the heat to which 
the child is exposed, the heavy air loaded with foul exhalations which 
it breathes, determines a condition of the health in which the digestive 
organs can no longer digest properly the food offered them. In both 
oases the same result is produced. In the first, the stomach cannot 
change the originally improper character of the food into healthy ma- 
terial. In the second, the diseased and enfeebled organ loses the power 
to digest even proper food. In both the alimentary canal is filled with 
the products of an improperly digested food. Whether these unhealthy 
products in the alimentary canal act chiefly as local irritants to the 
mucous membrane, and thus determine the tissue-changes met with ; 
or whether, as Eilliet and Barthez suppose, some morbid condition of 
the blood is brought about, which of itself gives rise to the changes in 
the mucous membrane through a morbid action of the diseased blood 
on the nervous system, and particularly on the sympathetic nerves, we 
cannot say. Most probably they act in both ways, and the resultant 
efl'ects are the consequence of the two trains of diseased action set uj), 
the local and the general. 

In either case a constitutional condition is brought about, the essen- 
tial feature of which is a slow innutrition or inanition. It is altogether 
probable, moreover, that a condition partaking of the scorbutic, must 
be induced, so that we have, after the disorder has lasted for several 



398 ENTERO-COLITIS. 

days or weeks, the general debility of a slow inanition, and blood-alter- 
ations which resemble those of scurvy. 

Symptoms ; Duration. — In infants the acute form of entero-colitis 
generally begins with restlessness and fretfulness. The mother ob- 
serves that the child sleeps less than usual and for shorter periods^ and 
that its sleep is uneasy and broken by sighing or moaning, or by occa- 
sional expressions of pain flitting across the face. It takes the breast 
less frequently, and is satisfied to nurse for a shorter time, showing 
thereby an evident diminution of appetite. At the same time it is apt 
to reject its milk in larger quantities than usual, and this is often ob- 
served to have a very acid smell. After these symptoms have lasted a 
few days, and sometimes without them, the peculiar symptoms of the 
disease, the diarrhoea and other abdominal symptoms, make their ap- 
pearance, and are accompanied by febrile reaction in most cases. 

In older children the acute form may come on suddenly, with diar- 
rhoea, loss of appetite, thirst, sometimes vomiting, abdominal pain and 
fever from the first; or, as happens very frequently, the case begins 
with slight diarrhoea, unaccompanied by fever or other signs of sick- 
ness, and it is not until after several, or eight, ten, or even more days, 
that signs of inflammation make their appearance. 

After the disease is established, the most important symptoms are the 
following. The diarrh(Ba^ which is the most prominent and characteris- 
tic, presents various characters. In order to appreciate this symptom 
as its importance requires, the practitioner ought always to see the nap- 
kins of the child at least once, and often more frequently, in the day. 
It exists in almost all cases of entero-colitis, in the erythematous and 
follicular inflammations, and in the ulcerations and softening which ac- 
company or succeed simple inflammation. It is seldom absent, and yet 
that it is so sometimes, is proved by the facts mentioned by MM. Eil- 
liet and Barthez, who state that they have calculated, from their cases, 
that it is wanting in about one of every twelve cases of inflamma- 
tion or softening of the intestine. They add, however, that it is absent 
only in slight attacks, and is always present when the disease is severe. 
It varies greatly as to the frequency, abundance, and character of the 
stools. It varies also in its mode of progress, so that it presents great 
difl'erences as to all these points from day to day, and at difl'erent por- 
tions of the same day. We may remark, in general, however, that in 
proportion to the severity of the inflammation, so is the diarrhoea vio- 
lent and constant, and that it usually increases as the signs of inflam- 
mation become more and more marked. It is rare to have severe diar- 
rhoea when the anatomical lesion is of slight extent, though this does 
sometimes happen. The number of the stools, as has been stated, is 
exceedingly variable. This depends in great measure upon the vio- 
lence of the case; for, while in those which present the symptoms of 
an inflammation of small extent the stools seldom amount to more 
than six or eight a day, in those in which the evidences of more exten- 
sive and severer inflammation are present, there will be fifteen, twenty, 



SYMPTOMS — DURATION. 399 

twentv-five, or even more per diem. The consistence of the stools may 
vary between that which characterizes them in a state of health, and 
that of the thinnest serous fluid. The materials of which they are com- 
posed consist chiefly of mucus, bile, serum, small portions of feculent 
matter, portions of undigested casein or other food, and blood. M. 
Bouchut {loc. cit..\:>. 219) describes those of very young children as pre- 
sentinor the following characters: 

1. They are semifluid, homogeneous, greenish, and similar to cooked 
vegetables; neutral. 

2. Semifluid, homogeneous and green ; often acid. 

3. Semifluid, heterogeneous, greenish, and mixed with yellowish 
fragments of ordinary fseces; neutral. 

4. Semifluid, heterogeneous^ greenish, and mixed with fragments of 
undigested casein; acid. 

5. Difiluent, greenish, heterogeneous^ composed of a large quantity 
of water in which float yellowish and greenish or whitish particles; 
acid. 

6. Difliuent, greenish, like the preceding, and mixed with gas of a 
mawkish and sometimes sourish smell. 

7. Difiluent, completely serous. 

8. Bloody stools are very rare at this age. 

Such are the appearances of the stools in children who have not 
completed the first dentition. After the epoch of the first dentition the 
disease becomes much more rare, and when it occurs, is generally of a 
milder character, so that the discharges diff'er less from their healthy 
characters. Under these circumstances, they are usually less frequent, 
not often exceeding six, eight, or ten in the day, and retaining gener- 
ally their yellow color or becoming brownish; they are commonly of 
a semifluid consistence, and may be called bilious. When, on the con- 
trary, more frequent, they become fluid, abundant, mixed with mucus, 
and are either of a light yellow or brownish, or more rarely, of a 
greenish color. In some cases there are, in addition to the substances 
mentioned, pus, which indicates ulceration of the lower portion of the 
intestine, and fragments of false membrane. Moreover, it is very com- 
mon in older children to observe traces of blood in the stools, some- 
times in considerable quantities. We may remark that we have several 
times met with stools containing blood in children within the year, 
but much less frequently than after that age. The presence of blood 
generally coincides with small and frequent stools, attended with much 
straining, and often severe pain, and almost always indicates follicular 
inflammation and ulceration of the large intestine. 

The serous fluid alluded to sometimes constitutes the whole of the 
discharge, so that the napkins are merely wetted through, without 
any or but a very small quantity of solid matter being left upon them. 
This kind of stool is vevy frequent in the cholera infantum of this 
country. The 06?or of the stools is important. In the beginning, while 
the discharges still retain some of their natural characters as to color 
and consistence, it is often very offensive, but as the case goes on, and 



400 ENTERO-COLITIS. 

the greenish color predominates, it is either sour, or becomes very 
slio'ht. In some violent cases, in which the discharge consists of a 
watery, dark-brown fluid, the odor is fetid. 

After diarrhoea, the most important symptoms are those which con- 
cern the form, size, and tension of the abdomen, and the presence or 
absence o^ pain or tenderness on pressure. In infants the abdomen is 
more distended than usual; but^ according to Bouchut, the tension 
depends on the muscular effort made by the child to resist the hand of 
the physician. He says that when it is carefully examined, while the 
attention of the child is attracted in some other direction, it is found 
to be soft and supple, and rarely painful to the touch. In older chil- 
dren it is, in many acute cases, but not in all, enlarged, sometimes 
tense and sonorous, and very generally painful to the touch. The seat 
of pain is variable, but generally it is in one of the iliac foss83 or at the 
umbilicus. It is seldom acute, though the child not unfrequently 
shrinks away and cries out, as though it were excessive, from fear of 
the examination. It is easy to distinguish when the pain is real and 
when apparent, by withdrawing the attention of the child, by some 
device, from the examination, in which case it will cease to notice the 
palpation; or by touching some other part of the body, when, if the 
crying and shrinking depend on fear or nervous excitation, they will 
be as violent as when the abdomen is touched. Pain to the touch is an 
important symptom, as it is very generallj^ indicative of acute enteritis. 
Gurgling is rare, according to MM. Eilliet and Barthez, in ordinary 
entero-colitis, though very generally present in typhoid fever. 

Vomiting is very common in young infants, and is generally repeated 
several times a day. In severe and rapid cases it is a very troublesome 
and alarming symptom. In older children it is much less common, and 
is never really violent, except in some of the most acute cases. In 
them it is confined to the first few days of the attack. 

After the diarrhoea is fairly established, young infants are almost al- 
ways either very irritable, peevish, and restless, or weak, languid, and 
subdued. Their slumber is short and disturbed, and generally they 
sleep much less in the twenty-four hours than when in health, unless 
under the influence of anodynes. Older children are generally some- 
what restless and irritable, but much less so than infants. There is 
seldom any disorder of the intelligence, though in acute cases there is 
sometimes slight delirium or headache. Fever exists in all acute cases. 
It is seldom continuous in infants except for the first few days, after 
which it almost always assumes the remittent type. It is marked by 
increased frequency of the pulse, which rises to 120 and 140, or in bad 
cases much higher; by heat of skin, often intense during the exacerba- 
tions; b}' thirst and diminished appetite; and by dryness and heat of 
the mouth. In older children the pulse is not generally so high as in 
infants, and in man}- of the mild cases the fever is very slight or there is 
none at all. In acute cases, however, it is sometimes continuous, and 
marked by rapid pulse and great heat of skin. 

The toigiie is generally normal, though sometimes red on the edges 



SYMPTOMS — DURATION. 401 

and tip in acute cases. It is seldom dry, except during the fever. The 
appetite is almost always lost, and the thirst generally increased, though 
to a less degree than in diseases of the stomach. 

The countenance presents nothing peculiar, except that the features 
are, according to MM. Eilliet and Barthez, drawn down towards the 
inferior portion of the ftice. Emaciation always takes place as the dis- 
ease progresses, and in very severe cases occurs with the greatest 
rapidity, so that in a very few days the child will be reduced from an 
appearance of vigor and strength, to that of the greatest debility. As 
this occurs the flesh loses its firmness, the skin hangs in folds upon the 
trunk and limbs, and is dull and dirty in its tint, the eyes become 
sunken and surrounded with bluish circles, and the whole appearance 
of the child is that of misery and exhaustion. 

In infants, it is very common to meet with erythema of the buttocks 
and thighs, produced by the contact of the acrid stools and urine with 
those parts. This symptom is said by Bouchut to exist in five-sixths 
of the cases. We feel quite sure that it does not exist in so large a 
projDortion of those which occur in private practice, though we have 
met with it in numerous instances. When severe it is generally accom- 
panied by papules, which ulcerate after a time and form superficial 
ulcerations upon the skin. These ulcerations sometimes run together, 
and become of considerable size and depth. In the form of the disease 
met with in the children's hospitals in Paris, erythema and ulcerations 
of the heels and internal malleoli are also met with, and constitute a 
serious complication in the case. They are said to depend on want of 
cleanliness, and the rubbing together of the feet of the child, unpro- 
tected by covering. We have never met with them in private practice. 

The duration of the disease is stated by the French writers to be 
generally about fifteen days, at the end of which time convalescence is 
usually established. It may be shorter or longer. According to our 
own experience it is entirely uncertain. Most of the cases that have 
come under our notice have been rather shorter. The disease subsides 
gradually. The nuaiber of stools diminishes; they become less abun- 
dant and more consistent, and return to their natural color and odor; 
the pain on pressure, and the enlargement and tension of the abdomen 
disappear; and as this occurs, the fever subsides, the appetite returns, 
the temper improves, and the child enters into full convalescence. 

The chronic form of entero-colitis generally follows the acute, though 
it sometimes presents many characteristic features from the first. It 
differs from the acute form chiefly in the absence or the much slighter 
degree of fever and other constitutional symptoms in the early stage. 
The diarrhoea is less abundant and less frequent. At first the child re- 
tains its spirits and many of the signs of health. But gradually its 
strength fails, the temper becomes irritable, the complexion grows 
dark, sallow, and unhealthy, the skin becomes dry and harsh, and, in 
consequence of the emaciation which takes place progressively with 
the other symptoms, hangs in folds around the shrunken extremities, 
or is drawn tightly over the joints and other osseous protuberances. 

26 



402 ENTERO-COLITIS. 

The tongue is generally moist and natural, though in some cases red 
and dry, whilst in others it, together with the lips, partakes of the 
pallor which pervades all parts of the body. The abdomen is usually 
distended and sonorous on percussion, and may be painful or not on 
pressure in different cases, or in the same case at different periods of 
the disease; its parietes sometimes offer no resistance to the touch, so 
that the intestinal convolutions may be readily felt by the hand, or 
even between the fingers; and in some cases we have seen them so thin 
and relaxed, though the abdomen was more prominent than natural, 
that the outlines of the intestines, and even their peristaltic movement, 
were visible upon the exterior. The appetite generally persists in 
spite of the gravity of the disease, and is sometimes increased. The 
stools, as has been stated, are not so frequent as in the acute form, 
seldom numbering over six or ten in the day and night. They consist 
of the products of an imperfect digestion, and contain not unfrequently 
the alimentary substances in the state in which they were swallowed, 
mixed with mucus, serum, pus, and sometimes blood. Their consistence 
varies constantly, but they are usually semifluid. Their odor is seldom 
!iatural, and often extremely offensive. 

* The course of the disease is very irregular. Even in the worst and 
most prolonged cases intermissions or remissions occur, so that the 
child will often improve greatly for daj^s or weeks, and then suddenly 
relapse into as bad a condition as ever. In favorable cases these re- 
missions become more and more frequent, and the symptoms gradually 
improve, until at length the child is restored to health. In fatal cases 
death is occasioned by the utter deterioration of the general health 
which finally occurs, and the child perishes, worn out by long illness, 
or, as more frequently happens, some complication arises w^hich hurries 
on the fatal event. Thrush is a frequent complication of chronic en- 
tero-colitis, and doubtless often hastens the death by the impediment 
which it occasions to the nursing or feeding of the child. Yomiting 
has almost always occurred towards the close of the fatal cases that 
we have seen, especially in those in which extensive thrush was present. 

The duration of this form is of course very uncertain. It may last 
for weeks or months. We have known it to last two and three months 
in several cases, and in two others it lasted with occasional intermis- 
sions, in one a year, and in the other eighteen months. 

Diagnosis. — The diagnosis of acute entero-colitis is not difficult. 
There is no disease with which it is likely to be confounded. The 
characteristic features of the malady are the diarrhoea and other ab- 
dominal symptoms, and the absence of signs of other disease. The 
secondary cases are distinguished by the occurrence of the usual symp- 
toms of entero-colitis during the progress of the primary malady. 

The chronic form is not likely to be mistaken for any other disorder, 
unless it be the diarrhoea which occurs in tubercular disease, from w^hich 
it is to be distinguished by the presence in the latter of the signs of 
tuberculosis of other organs. 

Prognosis. — Acute entero-colitis is always a serious disease in in- 



PROPHYLACTIC TREATMENT. 403 

fants. The prognosis will depeDd in great measure on the circumstances 
under which the affection has been developed. It is much more unfav- 
orable in a child fed on artificial diet, either wholly or in part, than in 
one who is nursed at a fine breast of milk. It is more unfavorable also 
in weak and delicate than in robust and vigorous children, and in those 
of poor people, who live in crowded and unhealth}^ portions of cities 
and towns, whose habitations are small, damp, and ill-ventilated, and 
whose food is coarse and insufficient, or improper, than in those 
placed in more fortunate and more healthful hygienic conditions. It is 
a more dangerous disease in summer than in winter. In hospitals for 
children it is a very fatal disorder, owing to the bad hygienic conditions 
under which the inmates are placed. In children who have passed 
through the first dentition, the prognosis is, as a rule, favorable. The 
disease is seldom dangerous in such cases when it occurs as a primary 
affection, while, as a secondary affection, on the contrary, it is much 
more apt to be serious. 

The unfavorable symptoms are: great frequency of the stools; col- 
lapse ; violent vomiting or retching; and dangerous cerebral symptoms, 
as coma, rigidity of the limbs, paralysis, or convulsions. 

Treatment. — The prophylactic treatment is very important. It in- 
cludes attention to habitation^ diet, dress, and exercise. The most fre- 
quent causes of entero-colitis are high summer temperatures, residence 
in an unhealthj^ locality, and improper diet. A child may have been 
born of the most healthy parents; may be living, if an infant, on the 
most healthy food in the world, the milk of a perfectly sound woman, 
or, if it have been weaned, on the best possible substitute for breast- 
milk, one selected by the most consummate medical art; and yet, if it 
be the unfortunate resident of some low, crowded, and unclean part of 
any of our cities in the summer season, it has but small chance of es- 
caping inflammatory diarrhoea or cholera infantum, to be followed by 
chronic diarrhoea. Or, a child may be living in the best part of these 
cities, with every advantage that wealth and the medical art can give, 
and, if in the j)eriod of the first dentition, and the summer heats be 
great, it will be only too apt to have some form of the disease we are 
considering. Under the latter circumstances, its chance of escaping 
the disease will be vastly greater than under the first-named conditions, 
but the true proj)hylaxis is, where the parents are so situated as to be 
able to do that which is best for the child, removal from the city during 
the hot season (from the early part of June to the last week of Septem- 
ber) into some cool and healthy region of country. We have long 
thought that the best region to spend the summer in is a somewhat 
high and cool part of the country, where the breezes have full sweep, 
and where the topography is such that water runs off rapidly, or sinks 
fast into the soil. The seaside, if it be a point where there are no marshes 
and no malaria, and where the supply of milk and other wholesome 
food is abundant, is an excellent place. We have seen more remark- 
able sudden effects from the removal of a dangerously sick child to the 



404 ENTERO-COLITIS. 

seaside, than from a change to the interior; but, nevertheless, for a 
continued residence of three months, ^ve prefer a high interior locality. 

On the other hand, if a child be placed in the most flworable possible 
condition as to locality, and the diet be a radically bad one, a deficient 
or unhealthy breast, improper artificial diet, or a foolish allowance on 
the part of the mother or nurse to the child of a varietj^ of vegetables, 
of fruits, and especially of berries like currants or gooseberries (and we 
have known such things), it can scarcely escape the penalty of a fit of 
illness more or less severe. 

A child who is so unfortunate as to get a sharp attack of entero-colitis 
in June or July, is very apt to continue more or less sick during the 
rest of the summer, so that the true prophylaxis is to take it away from 
the city early in June to avoid this danger, and not to return until after 
the September heats are over. 

As the reasons for decisive medical action in any disorder cannot be 
too strongly demonstrated, and as this subject of removal is a very im- 
portant one, we think it well to advert here to the results of experience 
in this matter in the diarrhoea and dysentery of our armies during the 
late war. Here we have the experience of intelligent army medical 
officers in vast numbers of cases, — cases, too, so grouped together as to 
give opportunity for the most accurate observation. In the Sanitary 
3Iemoirs of the War of the Eebellion, collected and published by the United 
States Sanitary Commission (Chapter YlljOam^ Diarj'hoea and Dysentery, 
by Sanford B. Hunt. M.D , p. 291), will be found a most valuable essay on 
the causes and treatment of diarrhoea and dysentery, which no one can 
read without being impressed with the similarity (saving the ages of the 
patients) of those diseases to the one we are describing. At page 804, Dr. 
Hunt says : '• But in others the disease progressed, became follicular, and 
finally ulcerative. In the treatment of these, great difficulty was ex- 
perienced, from the fact that the patient was still exposed to the causes 
of this malady; and it came to be a fixed doctrine at Southern and 
Southwestern stations that confirmed cases had no security for cure 
except by removal to the North. This soon became a governmental 
policy, and hospitals were established in New England, along the Lakes, 
and in the Northwest, to which chronic cases were sent in great num- 
bers. Among patients not thus removed, but treated in Southern hos- 
pitals, much vacillation and irresolution were exhibited in the prescrip- 
tions of surgeons, as happens in all diseases, the treatment of which by 
drugs is usually unsuccessful. To trace the history of an individual 
case was to find that the prescriber had run the round of all remedies, 
from opium to astringents, from astringents to quinine, from quinine to 
bismuth, and from bismuth to nux vomica, from nux vomica to mercu- 
rials, returning almost always to opium as the drag, which at least alle- 
viated, if it did not cure." 

The dress ought to be suited to the weather. It is best to keep on 
the child, even in hot weather, a verj- thin and soft flannel shirt, with 
short sleeves. This should never be removed. A young infant should 
wear all summer long a thin and light flannel petticoat. A child a year 



HYGIENIC AND DIETETIC TREATMENT. 405 

old mav have the flannel petticoat removed for a few days when the 
temperature rises to above 85° or 90°, Avhen it suffers evidently from 
the heat; but so soon as the temperature falls to 85° or below, the pet- 
ticoat should be replaced. This happens only for a few days in our 
summer season, and the change should be made with great care, and 
only under the supervision of an intelligent and watchful mother or 
nurse. 

Exposure to the open air is another point in the prophylactic treat- 
ment which is of great importance. In country houses in the summer, 
a young intant may get nearly as much air as it needs, but in cities the 
air of houses is much more dull and stagnant, and the child ought to be 
carried out into the streets and squares for several hours morning and 
evening. If possible, it should be taken to drive into the open country. 
Short excursions, by rail or boat, for the children of the poor, who can- 
not escape from the city in summer, are very useful in carrying the 
child safely through the summer. But in all such jaunts after health, 
the parents should so arrange matters that the child shall be as little 
fatigued as possible. The best plan is to go in the morning and return 
in the evening, resting through the middle of the day at some point 
where the child can take rest and midday sleep, which are quite as im- 
portant as fresh air. Included in this subject is that of exercise. This 
becomes very important when the child is old enough to walk and run, 
for then an ignorant or thoughtless woman might think the more exer- 
cise the better, whereas it is necessary to watch such children very care- 
fully, since, if they are allowed or enticed to take undue exercise, the 
resulting fatigue becomes a positive cause of diarrhoea. A child of two 
or three years old should never be induced to take long and continuous 
walks; it ought to frisk and play, not walk straight ahead, like a man 
in training; for that kind of exercise, we have remarked, never suits 
children well. 

It has already been stated that one of the most frequent causes of the 
malad}^ is the attempt to bring up the child on artificial diet, and par- 
ticularly on one of an improper kind. It is clear, therefore, that to 
avoid the disease it is necessary that the child should, if possible, be 
nursed. If this cannot be done, the diet ought to be wisely selected 
and regulated in all its details by the phj^sician. The one most proper 
is evidently that which most closely resembles the natural aliment of 
the infant. For directions as to diet, we must refer the reader to the 
remarks upon diet at page 331, where we have discussed this point quite 
fully. 

Diet in the Attack. — After the disease has made its appearance, the diet 
should be very carefully regulated. This constitutes, in truth, the most 
important point in the treatment. If the child is nursing, it ought to 
be confined entirely to the breast, and should the nurse have a large 
quantity of milk, and the stools exhibit considerable quantities of un- 
digested casein, it must be somewhat restricted as to the frequency 
and length of time it is allowed to nurse; in other words, it must be 
moderately dieted for two or three days. Should there be the least 



406 ENTERO-COLITIS. 

suspicion that the milk of the nurse is unhealthy, it ought to be exam- 
ined as before directed, and, if found unhealthy in any respect, a new 
nurse must be provided. If the disease comes on shortly after wean- 
ing, and persists for several days in spite of careful diet and treatment, 
it is safest to restore the child to the breast. When this cannot be 
done, we must select that form of artificial diet which seems most suita- 
ble. The best is, in our opinion, the cow's milk prepared with the so- 
lution of gelatin in the manner already recommended, but made very 
weak for a few days. We have often found it necessarj'-, under these 
circumstances, to add four and even more parts of water to the milk, 
instead of two or equal parts, as is the usual custom. 

In older children the diet, for a few days, ought to consist of simple 
milk and water, or of thin preparations of arrowroot, rice flour, sago, 
tapioca, or wheat flour, made with milk, or milk and water, with small 
quantities of bread, or, if the child refuse such articles, panada, or light 
chicken- or mutton-water may be allowed. The quantit}^ of food, what- 
ever it be, must be determined very much by the child's instincts. 
When the a23petite continues, we can seldom go wrong in allowing as 
much of these simple foods as the patient will take. Still, the physi- 
cian ought to know accurately the amounts that are given, and if he 
finds the patient taking a full healthy average, or more, it will be best 
to restrict the quantity somewhat, and offer water frequentlj^, on the 
supposition that the little patient is taking its liquid food more from 
thirst than hunger; or else increase the water of the food, if he 
have reason to believe that the solid matter is in too large a propor- 
tion. 

Therapeutical Treatment. — We have found a large number of the, 
mild cases that have come under our notice to recover under very 
simple treatment. When the patient is an infant at the breast, before 
the period of dentition, the simple direction not to allow it to nurse as 
much as usual; the use of a warm bath morning and evening, if the 
skin be heated and the child restless and fretful ; the administration of a 
small dose of castor oil (half a teaspoonful to a teaspoonful), or of spiced 
syrup of rhubarb in the same quantity, with half a drop to a drop of 
laudanum, at the beginning of the attack, to remove any undigested food 
that may be lying in the bowels, followed in one or two days, if the dis- 
order continues, by some simple astringent remedy, generally sufiices 
to effect a cure. When, on the contrary, the case depends on an un- 
healthy or insufficient milk, when the child subsists entirely on arti- 
ficial food, and when the disease coincides with the process of dentition, 
the attack is kept up and aggravated by these causes, and it is more 
difficult to obtain a cure. In the former case the diet is, of course, of all 
importance; in the latter the gums must be carefully examined^ and if 
found to be swelled and inflamed, and the teeth near the surface, they 
should be freel}^ incised. After these matters have been attended to, 
the kind of treatment will depend on the character of the general symp- 
toms and the violence of the enteritic disorder. 

When the pain is violent, the discharges frequent, painful, and mixed 



THERAPEUTICAL TREATMENT MERCURY. 407 

with mucus, muco-pus, or blood, and the abdomen tense and painful to 
the touch, moderate local depletion by leeches may be used with advan- 
tage and safety in vigorous children. The leeches are best applied 
over the lower part of the abdomen. About six or eight American 
leeches, or two foreign ones, may be applied at the age of one or two 
years, so as to take about two ounces of blood. Of late years, however, 
we have not employed depletion so much as formerly, but use instead 
warm baths, poultices to the abdomen, or warm stupes, and refrigerant 
medicines. Small doses of the sulphate of magnesia and laudanum are 
very useful ; or we may employ spirit of nitrous ether, or solution of the 
acetate of ammonia with paregoric or laudanum, or the following mix- 
ture : 

R. — Sodse Bicarb., ^ss. 

Mass. Hydrarg., . . . . . . gr. iij. 

Tr. Opii Camph., gtt. l vel f^j. 

Syrup. Simp., f^ij. 

Aq. Month., f^xiv. — M. 

Dose, a teaspoonful every three or four hours. 

The warm bath, used at a temperature of 95° to 97°, twice or thrice 
a day, is most excellent. It is a good plan to wrap the child, immedi- 
ately on being taken out of the bath, in a warm muslin sheet, and over 
this a light blanket, and let it lie on the lap or bed for twenty minutes 
or half an hour. Tbe hot poultice or stupe recommended above, should 
be covered with oiled silk, secured by a towel pinned around the body, 
changed every three or four hours, and kept on for the greater part of 
the day, or for several days. 

Calomel has been so highly recommended and so long employed in 
these cases, that we feel some hesitation in saying how often it has dis- 
appointed us. Certainly we have found in many children that it was 
of no evident use, and in the old-fashioned doses of a grain or half a 
grain, we think it only adds to the irritation of the bowels. In doses 
of the twelfth and eighth of a grain, with chalk and opium, every two 
or three hours, we formerly thought it was sometimes useful, but we 
cannot resist the impression which years have given us, that the useful 
agents in these instances have been the chalk and opium, and especially 
the opium. The blue-pill mixture, recommended above, we still put 
trust in. Why blue pill should answer where calomel irritates, we do not 
pretend to explain, but such is the opinion to which experience has 
led us. 

Before quitting this question of the use of mercurials in diarrhoea, 
we wish to quote the results at which some of the more modern ob- 
servers have arrived, with the remark, as we pass on, that our own 
conclusions were much the same ten years ago as those expressed 
above. We shall do this even at the risk of being tedious, for we 
think the point a very important one. In the first place, we shall 
quote the opinion of one of the ablest of the United States army sur- 
geons, as to the use of this drug during the late war. The writer 
(^Outlines of the Camp Diseases of the United States Armies as observed dur- 



408 ENTERO-COLTTIS. 

ing the Present War, hy J. J. Woodward, M.D., Philadelphia, 1863), in 
the article on Chronic Diarrhoea, a disorder closely akin in many of its 
symptoms and anatomical lesions to tiie entero-colitis of children, says 
at page 262 : "Among the remedies liberally employed in chronic diar- 
rhoea is one group which can only be mentioned wn'th disapprobation. 
This is the mercurials, which are too frequently administered to gentle 
salivation in the form of blue pill or calomel, combined with opium and 
ipecacuanha. The authority of some of the most distinguished Ameri- 
can medical writers is in favor of the employment of mercurials in the 
chronic diarrhoea of civil life; yet when it is remembered that even 
those modern writers, w^ho most warmly advocate their general em- 
ployment in the treatment of inflammation, recommend them to be dis- 
continued as injurious whenever the process has gone on to ulceration, 
it would appear that even sound mercurialists would avoid using them 
in the form of chronic diarrhoea which is most common in the army. 

"Practically it will be found that although in some cases mercurials 
may succeed, as much less dangerous remedies would have done, in 
checking the progress of the disease^ yet that in the majority of cases 
their employment is accompanied by an increase of the debility, the 
loss of appetite, the anaemia, and the general constitutional symptoms, 
without any diminution in the frequency of the stools. They are, 
therefore, to be regarded as dangerous and inefficient, and their use in 
these cases has been completely abandoned by those surgeons who are 
most successful in the treatment of the disease." 

Dr. T. K. Chambers, of London (Clinical Medicine, London, 1864, p. 
517), in considering the treatment of diarrhoea in which the stools ex- 
hibit the products of acute inflammation, ssijs: "The drugs I have 
most trust in are calomel, ipecacuanha, and carbonate of soda. Of the 
first and second equal quantities, and a double quantity of the third, 
may be made into powders, of which from four to six grains, according 
to the child's age, maj^ be given every three hours. This is a tradi- 
tionary powder, but it is right to say that I have in a good many in- 
stances lately left out the calomel, and the case has done just as well, 
if not better, without it." 

Dr. J. L. Smith, of New York (op. cit., p. 379), says nothing what- 
ever about mercurials in his article on the treatment of inflammatory 
diarrhoea, from which we are led to suppose that he does not use them. 
He however quotes Dr. E. H. Parker as giving, wdien the condition ap- 
proaches that of dysentery, a mixture consisting of about ten grains of 
blue mass rubbed up in two drachms of syrup of rhubarb, to which is 
added one half teaspoonful of paregoric, and four ounces of chalk mix- 
ture. Of this the dose is a teaspoonful every two or three hours. Dr. 
Parker says that the " blue mass certainly does not act like the calo- 
mel, not producing in purgative doses so great prostration, and in small 
doses it does not lessen the proportion of fibrin in the blood, as is the 
case with calomel." Dr. Smith's comment on this is: "I have never 
used this mixture, having been generally satisfied with the effects of 
the castor oil mixture." 



THERAPEUTICAL TREATMENT — OPIUM. 409 

It is unnecessary to saj' any more upon the use of mercurials, and 
especiall}^ of calomel. We have quoted enough to show that our OAvn 
opinions find us in very good company. 

We regard opium as one of the most valuable remedies we have in 
the treatment of this disease. In a former edition of this work it was 
stated that some writers objected to its employment in the early stage 
as injurious, but that we had not been deterred from using it, except 
in cases presenting manifest signs of cerebral irritation in connection 
with the febrile symptoms ; but that when there has been nothing more 
than irritability, restlessness, and insomnia, when there was evident 
pain during the discharges, and when the latter have been very fre- 
quent, we had always made use of some of its preparations without 
hesitation, and certainly- without injury, but, on the contrar}^, with 
ver}^ great benefit. Our longer experience confirms us in this view 
and practice. The propriety of using large doses of opium in the early 
stages of cholera infantum may well be questioned, as it has come to 
be by some of the best observers in Asiatic cholera; but this matter 
will be considered under the head of that disease. In the disorder under 
consideration, which is one of an inflammatory catarrhal type, we have 
never seen the moderate use of opium do anything but good. When 
the nervous symptoms are very marked, if they be of the kind which 
denotes disturbance of the reflex functions of the nervous system rather 
than those indicating cerebral disorder, we find nothing which answers 
so w^ell our purpose as this remedy. When, however, there is unusual 
quiet, tending towards drowsiness or stupor, wath contraction of the 
pupils, we make use of it only with great caution and in very small 
doses. We are glad to find that Dr. Stokes also employs opium with- 
out hesitation. He says, "It is a remedy that requires caution in its 
exhibition, but one of great utility." It generally lessens the number 
of discharges, and very often diminishes the heat of skin and frequency 
of the circulation, by allaying the irritability of the nervous system, 
while at the same time it greatly promotes the comfort of the child. 
We have used it in the form of laudanum or paregoric, given in combi- 
nation with a laxative early in the case, or by enema, and afterwards 
in that of the Dover's powder or powdered opium. For a child under 
six months old half a drop of laudanum is enough to give by the mouth. 
Of the Dover's powder about a sixth or eighth of a grain may be ad- 
ministered mixed with two grains of chalk, to be repeated every two 
or three hours until three or four doses have been taken, or until the 
child shows some degree of drowsiness from the action of the opium, 
after which it ought to be suspended for six or eight hours, and then 
resumed. Or the opium may be given in the form of laudanum com- 
bined with the sulphate of magnesia as recommended above. The old- 
fashioned castor oil emulsion, in the proportion of one drachm in a one 
or two-ounce mixture, with half a drop of the deodorized laudanum to 
each teaspoonful of the mixture, is often very soothing and beneficial. 
When there is marked tenesmus, with frequent small evacuations, opium 
may also be used with great advantage by the rectum, either to the 



410 ENTERO-COLITIS. 

exclusion of any in the mixture, or in addition to that, taking care to 
graduate the quantity by the degree of drowsiness that may be induced. 
At one year two drops in one or two teaspoonfuls of water or thin 
starch-water maybe used two or three times a day. In such cases, 
suppositories are sometimes retained better than enemata. A twelfth 
to a sixth of a grain of powdered opium, made up with cocoa butter, 
may be given instead of the injection. 

Generally speaking the acute constitutional symptoms either subside 
or disappear under the above treatment, and very often the diarrhoea 
also ceases and the child recovers. When, however, the diarrhoea per- 
sists, it is necessary to resort to two other classes of remedies, upon 
which great reliance is placed in the treatment of this affection. These 
are astringents and absorbents, of which the most important are prepared 
chalk, powdered crab's-eyes, bismuth, acetate of lead, rhatanj^, kino, and 
catechu. The chalk may be used in the form of the officinal mistura 
cret8B, a teaspoonful of which is given after each loose evacuation, or 
several times a day. When the case is severe, the efficacy of this remedy 
is much increased by the addition of tincture of krameria, in the pro- 
portion of a drachm to two or three ounces of the mixture, of some 
opiate preparation, or of ten or fifteen drops of the aromatic sy^up of 
galls (to be described presently) to each teaspoonful. Chalk may be 
used also with great advantage, as stated above, in powder, combined 
with Dover's powder. 

The powdered crab's-eyes will sometimes arrest cases in which pre- 
pared chalk fails to produce any effect. It is generally employed in 
mixture. The formula we employ is the following : 

R. — Ocul. Cancror. Pulv., gj. 

Pulv. Acacia9, ^ij. 

Sacch.Alb.,. 9J. 

Aquse Fontis, Aquas Cinnamom., aa . . . f^iss. — M. 
A teaspoonful to be given four, five, or six times a day. 

M. Bouchut recommends the following prescription of Hufeland's : 

R. — Ocul. Cancror. Pulv., gr. x. 

Aqute Foeniculi, Syrup. Ehei, aa . . . f^ss. — M. 
Give a teaspoonful every hour. 

Subnitrate of bismuth has been highly recommended, for a number of 
years past, as a remedy in diarrhoea. Dr. Woodward (op. cit., p. 258) 
quotes Assistant-Surgeon Dr. John B. Trask, U.S.A., as lauding it very 
highly in the chronic diarrhoea of the araiies during the late war, and 
in California and Oregon, especially in those cases in which there is 
nausea or other disorder of the stomach. Dr. Woodward states that 
" he has given it a fair trial, and while he is far from regarding it as a 
specific, believes it to be a most valuable article in both simple, irrita- 
tive, and in chronic diarrhoea." Dr. Trask prefers to give the whole 
quantity for the day in a single dose ; but Dr. Woodward states that 



THERAPEUTICAL TREATMENT — ASTRINGENTS. 411 

this view does not correspond with the general experience on the sub- 
ject. It may be given in doses of one to two grains, to children one 
year old, every two or three hours. It can be administered in powder 
Avith sugar alone, or combined with prepared chalk, or in mixture with 
simple syrup, or ginger or acacia syrup, and some aromatic water. We 
have employed it quite freqnentl}^ but, on the whole, have not found it 
so effective as Ave had been led to hope. 

Acetate of lead has been highly extolled by many writers in the treat- 
ment of the diarrhoeas of children. We have had but little experience 
in its use, and are, therefore, unable to offer an opinion in regard to the 
influence which it may exert. It may be given in doses of from a sixth 
to an eighth of a grain, alone^ or combined with chalk or Dover's 
powder, every two hours. Krameria, kino, and catechu maj^ be exhibi- 
ted alone, in the form of infusion or solution, or they may be given in 
conjunction with the chalk mixture. We have frequently employed 
the tincture of krameria in the latter way, and believe it adds very 
much to the efficacy of the remedy. About one or two drachms may 
be added to two ounces of the mixture, and the usual dose given. We 
have used, with much advantage, either alone or with chalk or crab's- 
eyes mixture, an aromatic syrup of galls, in the dose of from fifteen to 
forty drops three or four times a day, or, when the discharges are very 
frequent, every two or three hours. It is prepared according to the 
following formula : 

R.— Gallfe Opt. Pulv., gss. 

Cinnamom. Pulv., ........ ^ij. 

Zingib. Pulv., ........ ^ss. 

Spts. Vini Gall. Opt., Oss.— M. 

Let the ingredients stand in a warm place for two hours, and then burn off the 
brandy, holding some lumps of sugar in the flames. Strain through blotting-paper. 

Dr. Eberle {loc. cit,, p. 221) highly recommends the root of the 
geranium maculatum. He says it makes an "agreeable and efficient 
astringent,'' and is less apt to derange the digestive organs, and occa- 
sion irritation of the mucous membrane of the bowels, than kino. He 
uses it in the form of a decoction made with milk, by boiling an ounce 
of the fresh root in a pint of milk until half is evaporated. The dose 
is from a teaspoonful to a tablespoonful four or five times a day, 
according to the age of the patient. 

The nitrate of silver is highly recommended as a remedy of late years 
by several writers. It is given both internally and by enema. The 
modes of administration will be described in the remarks on the treat- 
ment of the chronic form of the disease. 

Revulsives are often of much service in the treatment of this, as of 
almost all the diseases of childhood. When there is much restlessness 
and irritability, with heat of the head and trunk, and coolness of the 
extremities, it will be found that mustard foot-baths, or sinapisms to 
the extremities, often allay these symptoms, and greatl}^ comfort the 
little patient. When the abdomen is tense and painful, and the dis- 



412 ENTERO-COLTTIS. 

charges preceded or accompanied by movements or crying indicative 
of pain, the application of a poultice of mush and mustard from time 
to time, to be followed by a simple mush poultice, sometimes acts very 
usefully. 

Tonics and stimulants are often necessary in weak and delicate chil- 
dren from an early period in the attack, and in those who are stronger, 
after the disease has lasted for some time, and the acute symptoms 
have ceased, and been followed by weakness and exhaustion. The 
best tonic is, probabl}', sulphate of quinine, in doses of from a quarter of 
a grain to a grain three times a day, continued for one, two, or three 
weeks if necessary. Old hrandy has answered better in our hands as a 
stimulant, than wine, wine-whey, or any of the tinctures. It may be 
given to the youngest children in doses of from five to ten drops every 
two hours, or a teaspoonful may be added to a wineglassful of sweetened 
water, and a teaspoonful given whenever the child will take it. We 
have been obliged, in several cases, to continue the use of the brandy 
for three, four, and five weeks. At the time when we are obliged to 
resort to this class of remedies, it is almost always necessary also to 
pay attention to the improvement of the diet. The proportion of milk 
to water ought to be increased, if it has been small heretofore; and we 
should employ every means to induce the child to take a sufficient 
quantity without overloading the stomach. At this stage small quan- 
tities of animal broths are proper, or the child may be allowed to suck 
pieces of juicy meat, or to eat very finely minced meat of chicken or 
mutton. The diet is in fact a most important part of the treatment at 
this period. Dr. Stokes saj'S of it, that "many children are lost by the 
practitioner neglecting this point." 

Occasionally, indeed quite frequently, vomiting becomes a most 
troublesome symptom in entero-colitis. When it occurs at rare inter- 
vals, and without much distress to the patient, it needs no attention, 
since it is to be supposed that the physician has already arranged the 
hygienic and therapeutical treatment so as to suit the ordinary condi- 
tions of the disorder. But when vomiting becomes frequent and vio- 
lent, so that the child rejects a large proportion of all that is given to 
it, and when, between the acts of vomiting, the little thing refuses 
almost everything that is brought to it, all its usual foods, medicines, 
and sometimes even water, it is evident that the child has a more or 
less positive sense of nausea which causes loathing of food, and the 
symptom becomes a serious complication which requires special atten- 
tion and treatment. In such cases, there is no use in forcing food or 
drugs which it loathes upon the child, unless all other means have 
failed, when of course, we must attempt to make it take concentrated 
foods in small doses. The better plan, at first, is to change the diet in 
toto — to abandon milk and all its preparations for two or three days, 
if these excite disgust — and give light beef or chicken tea, just touched 
with salt, or raw beef, or, if this also is refused, cold extract of beef 
in one or two tablespoouful or wineglassful quantities, or pieces of 
juicy and rich beef very slightlj^ cooked, to be sucked. Or we may 



THERAPEUTICAL TREATMENT. 413 

try small portions of yelk of egg, hard boiled, or what we have 
often found was eagerly taken in such conditions, wine-whey, of 
which we have given, in the second year of life, as much as a tum- 
blerful in twenty-four hours, and this without the slightest effect of 
undue stimulation, febrile heat, or excitement. Sometimes, when the 
child refuses its ordinary milk persistently, or vomits it so soon as 
taken, it will drink willingly, and retain verj' well, lime-water and 
milk, in the proportion of one of the former to two or three of the 
latter, with just enough brand}' to change the taste. We know that 
some medical men object entirely to the use of stimuli in children on 
two grounds : 1. That alcohol has no remedial power whatever, or that 
it is positively injurious in all cases. 2. That its use tends to produce 
that pernicious taste for stimulants which engenders the habit of drunk- 
enness. To the first objection we can only reply that our observation 
and experience have led us to a different conclusion, and that, when 
employed in certain conditions of the vital powers, which we have 
carefully endeavored to describe, stimuli are of the highest value as a 
therapeutic means. To the second we reply that we have never, so 
far as very careful observation goes, produced a drunkard by any use 
Ave have made of them. We agree that physicians ought to be very 
careful not to employ them in any attractive form, as a long-continued 
remedy, in children over six or eight years of age. When we desire 
to use any form of alcohol in a chronic case in children over the age 
mentioned, we always give some of the bitter tinctures or elixirs. 
When possible, we alwa^^s order the oldest and most delicate brandy 
that can be procured. As to the quantity, this must depend on the 
age of the patient, the instinct and idiosyncrasy of the child, and the 
degree of severity of the case. At the age of six months, from ten to 
fifteen drops may be given every two or three hours in two or three 
ounces of the lime-water and milk; and at one and two years, from 
twenty to twenty-five drops in from four to six ounces of the milk food 
every two, three, or four hours. It may be a sign of the old Adam in 
the poor little sufferer, but we have often known children to take, for 
days together, milk with brandy in it, who would not touch the milk 
without this addition. We cannot but think that in such cases it is an 
instinct for a useful agent, like the appetite of patients in typhoid or 
typhus fever, in certain of their phases, for wine or brandy, which dis- 
appears when the necessity for it passes away, as has been so well de- 
scribed by Dr. Corrigan, of Dublin, in his able little essay on the treat- 
ment of Irish typhus. 

Under these circumstances, all medicines which disgust the child must 
be laid aside. A bitter, or nauseous, or gritty dose will, in such states, 
surely cause vomiting, as will, in older persons, under such conditions, 
an odor or taste, or even an idea. We have seen a little infant, sick 
with diarrhoea, who was sitting languidly upon the floor, made to gag 
and retch, by chancing to pick from the floor a piece of softened bread. 
The impression produced upon the tactile sense of the fingers by the 
wet and mushy substance caused sickness at once, as the filing of a 



414 ENTERO-COLITIS. 

saw sets the teeth of a delicate nature on edge, and brings water into 
the mouth. All offensive and bitter doses must be abandoned therefore. 
"We have often used, in such cases, the following prescription with much 
benefit : 

R. — Liq. Morpli. Sulphat., n^xxxij. 

Acid. Sulph. Dil., ti^xv. 

Curacoa, . . . . . . • . f^ij- 

Aqu93, f^xiv.— M. 

Dose, a teaspoonful ever}^ hour or two liours, at the age of six months to a year. 

For older children, the proportions of the opiate and acid must be 
increased. When the nausea subsides or passes away, or when the 
child becomes drowsy, the intervals between the doses must be length- 
ened, and as the symptoms disappear, the other remedies necessary for 
the diarrhoea may be resumed, and so too of the food. Dr. J. L. Smith, 
of New York, states that the best remedy he has used for vomiting is 
the neutral mixture, as follows : 

U. — Potass. Bicarhonat., ..... gr. xxv. 

Acid. Citric, gr. xvij. 

Aquae Araygd. Amar., .... f^j. 

Aquse, f^ij. — M. 

One teaspoonful to a child from eight to twelve months old, repeated according to 
the nausea or vomiting. 

Creasote is also sometimes very useful. Dr. Smith says that in the 
Nursery and Children's Hospital of New York, this remedy is used, 
given in the proportion of an eighth of a drop in a teaspoonful of lime- 
water, in a teaspoonful of milk or breast-milk, and has been found suc- 
cessful in a certain proportion of cases. 

Treatment of Chronic Entero-colitis. — The management of the 
hygiene of the patient is more important than any other part of the 
treatment, in this, as in nearly all the diseases of the digestive organs 
in children; for cases will often recover when the diet, drinks, and ex- 
ercise are properly regulated, without the use of any drugs whatever, 
whereas, most assuredly, but a small proportion of them would termin- 
ate favorably under the best and wisest therapeutical medication, were 
the hygiene of the child neglected. The remarks that have been made 
as to the diet most proper in the acute form will apply here. If the 
child have been weaned only a few weeks before the time at which we 
are consulted, and the case is at all serious, it is better to advise the 
procuring of a wet-nurse. We have several times known cases of the 
disease which had resisted the most carefully managed artificial diet 
and therapeutical treatment, recover in a few days after the child had 
been restored to the breast. It is often, however, impossible to follow 
this course, from the refusal of the parents to obtain a nurse, or of the 
child to take the breast of a stranger, and we are obliged to rest con- 
tent with artificial food. We believe that the kind of diet which suits 
the largest number of children is one of milk. During a number of 



DIET IN THE CHRONIC FORM. 415 

vears past, ^e have found the gelatin food, already described, to answer 
better than any that we have ever essayed. It ought to be made very 
lio'ht and thin. About a scruple of gelatin should be dissolved by 
boiling in half a pint of water. Towards the end of the boiling, a 
gill of cow's milk, and a teaspoonful of arrowroot made into a paste 
with cold water, are to be stirred into the solution, and from one to 
two tablespoonfuls of cream added just at the termination of the cook- 
ing. It is then to be sweetened moderatel}^ with white sugar, when 
it is ready for use. The whole j^reparation should occupy about fifteen 
minutes. 

When cow's milk, mixed with water alone, or prepared in the man- 
ner just recommended, evidently disagrees, we have sometimes found 
cream with water alone, or better still, with the solution of gelatin in 
water, in the proportion of one part of cream to five or six of the latter, 
to suit very well. In other cases very carefully prepared beef tea or 
chicken or mutton water, given several times a day or but once, accord- 
ing to the taste and fancy of the child, will answer better. It some- 
times happens that the child will refuse everything that has been men- 
tioned, and yet the prostration and emaciation are such as to make it 
essential to procure some aliment that it will consent to take. We have, 
under such circumstances, given small portions of bread and butter, or 
stale sponge-cake, with weak brandy and water, if the child is old 
enough to swallow solid food. Sometimes it will eat sm^all quantities 
of meat, and when this has been the case, we have not hesitated to allow 
a chicken-bone, with a little meat attached to it, or a piece of ham, 
or better still, a portion of roast beef, or of the tenderloin of beef-steak, 
to be held in the hand and sucked; or we may give the white meat of 
chicken cut up very fine, or torn into the finest shreds. Of the latter 
about a teaspoonful is sufficient for the first day, given with a little 
brandy and water. The quantity can be gradually increased afterwards. 
We have of late years also given small quantities of raw beef in many 
cases, minced very fine and flavored with salt, or ptrepared in the man- 
ner described below,^ and have found it to be readily digested and to 

1 The use of raw meat in the diarrhoea either of infants deprived of their mothers' 
milk, or of weaned children, was recommended by Weisse, of St. Petersburg, as long 
ago as 1840 fOppenheim's Journal). Of late years it has been extensively used with 
excellent results, and is highly praised by Trousseau and other eminent authorities. 
The administration of the muscular tissue itself appears much more useful than any 
form of beef essence or soup, probably for this reason among others, that these fluids 
pass too quickly through the intestinal canal. The best meat for the purpose is the 
fillet of beef, though fine mutton may also be used. It should be cut very fine, and 
according to Trousseau, pounded in a mortar and strained through a sieve or cullen- 
der ; the pulp, thus separated from the cellular texture of the meat, may be rolled 
into small balls in salt or powdered sugar. 

The quantity upon the first day should not exceed three drachms, given in divided 
doses; but it may be doubled on the successive days, until young children may take 
from six to ten ounces a day. Under this regimen the diarrhoea frequently ceases, 
and the children quickly recover their plumpness and natural spirits. 

Trousseau calls attention to the fact that the stools are frequently red and fetid at 



416 ENTERO-COLITIS. 

agree well with the little patients. There is another article which we 
have sometimes given when children have been exhausted for want of 
food, and when they require constant change in order to be tempted to 
take it. This is the yelk of a hard-boiled egg, which has the advantage 
of being very nutritious if digested, and of not being injurious should 
it happen to pass into the bowel in the crude state, as it falls into a 
state of fine powder, which is not irritating to that organ. 

The quantity as well as character of the food is of the utmost impor- 
tance, and should be strictly regulated by the physician, and attended 
to by the mother or nurse. As a general rule the child may be allowed 
as much as it wants of proper food, since the appetite is almost always 
greatly diminished, and it is not likely, therefore, that too much will be 
taken. If, however, there is disposition to nausea or vomiting, ov if 
the appetite remain as good as usual, the quantity must be restricted. 
The difficulty in most cases is to get the patient to take enough, and not 
to prevent it from taking too much, for we have very often ascertained, 
upon careful inquiry, that the quantity was entirely too small to sup- 
port the strength of the constitution. A hearty child six months old, 
fed solel}' on artificial food, will generally take a quart of food in the 
twenty-four houi's, while at a year old it will take usually fully a quart 
or three pints of fluid nourishment, besides eating small quantities of 
solid food. Now, we have frequently known children laboring under 
chronic entero-colitis, not to take more than one or two gills of food in 
the day, which is manifestly much too little. When this is the case, 
therefore, we should always endeavor to stimulate the appetite and di- 
gestion by means of tonics and stimulants, and by causing to be pre- 
sented to the child such a variety of food as may entice it to take a 
larger quantity than before. 

In connection with this most important matter of the food, we will 
again quote from Dr. S. B. Hunt (^op. cit., page 305), to show the results 
of his experience in the use of foods in chronic inflammatory diarrhoea 
in the army. For the sake of any non-professional reader, we will state 
that by albuminoid food Dr. Hunt refers to meat, meat-broths, eggs, 
&c. ; and by antiscorbutic food he means tomatoes, fresh fruits, onions, 
&c. Dr. Hunt says: "The value of drugs was, perhaps, overestimated 
in this, as in all other diseases of assimilation, and only a careful avoid- 
ance of the original causes of the malady, and an equally careful recog- 

first, even when the nature and abundance of the diarrhcea have already undergone 
a favorable change. 

In a second article upon this subject (Jour, fiir Kinderkranheiten, January and 
February, 1858), AYeisse calls attention to the fact that in many children who had 
been treated by raw beef, tapeworms have been developed. As these worms were 
all specimens of taenia solium, which is not indigenous in St. Petersburg, it is prob- 
able, as suggested by Yon Siebold, that they had been conveyed- in the undeveloped 
state in the fle^h of oxen, brought from distant points. We are not aware that this 
unfortunate consequence has been observed frequently in other localities, and cer- 
tainly in the quite numerous cases in which we have ourselves administered raw 
meat to children, no entozoa have been developed. 



TREATMENT OF THE CHRONIC FORM. 417 

nition of their continued existence in the system, could secure any de- 
gree of success. The scorbutic and malarial taints were almost uniformly 
present, the former very frequently in as pronounced a form as the 
latter. The bowels, enfeebled by the inflammatory process, were un- 
able to perform their normal function of the digestion of starches, and 
the diet, therefore, became necessarily albuminoid. A full nutritious 
diet of albuminoid and antiscorbutic food assumed the first importance 
in the treatment. Coupled with this came pure air and absolute cleanli- 
ness. And, with these hygienic measures alone, when they could be 
properly enforced, it was possible to treat chronic diarrhoea and dysen- 
tery with a fair degree of success, even in the great heats of a Southern 
summer/' These views confirm what we have said above, that milk, 
meat, raw or cooked, broths, eggs, gingerbread, tomatoes, bread and 
butter, and we may add currant-jelty, make the best food for children 
over two and three years of age. Even in children of eight months 
and a year or upwards of age, milk and beef or chicken tea ought to 
form the chief diet. The starches, such as arrowroot, barley, wheat 
preparations, <fcc., do not answer, except in very small quantities cooked 
in milk. We saw one child, a year old, weaned in August in conse- 
quence of the illness of the wet-nurse, whose life was apparently saved 
in dysentery by Liebig's cold extract of beef, and by its fortunately 
having developed a strong taste for the sucking of large pieces of rap- 
idly and slightly cooked beefsteak. 

The therapeutical treatment of the chronic form consists principally in 
the administration of tonics, astringents, and absorbents. Of these the 
most important are the bismuth, powdered chalk and crab's-eyes, and the 
diff'erent vegetable astringents, which have already been noticed in the 
remarks on the acute form. These are to be given in the manner there 
recommended, and it is therefore unnecessary to repeat what has already 
been said. In addition to these there are some remedies which are par- 
ticularly adapted to the chronic form of the disease. Amongst them 
is nitrate of silver. Dr. Eberle (op. cit.^ p. 251) says he has found its 
internal administration to produce the happiest efi'ect in a few in- 
stances. His prescription was a grain of the nitrate dissolved in an 
ounce and a half of gum arable water, with the addition of twenty 
drops of laudanum. The dose was a teaspoonful three times a day. 
He adds that he has never " known the slightest inconvenience to re- 
sult from the use of this article in chronic mucous inflammation of the 
bowels, when administered in a mucilaginous solution and in very small 
doses." It has been much used of late years in France. MM. Trous- 
seau and Pidoux recommend its internal use in the chronic diarrhoeas 
of children occurring during dentition, after bismuth, powdered crab's- 
eyes, and diet have failed to effect a cure. Their formula is as follows : 

R. — Argent. Nitrat., gi'- i- 

Aquae Destillat., f.^vj. 

Syrup. Sarsap., f^ijss. — M. 

To be given in eight or ten doses. 

At the same time, they employ an enema composed of a grain of the 

27 



418 ENTERO-COLITIS. 

nitrate in three ounces of distilled water. It is highly recommended 
also in these cases by Hirsch, of Xonigsberg, His formula is as follows : 

R— Argent. ISTitrat. Crystal., gr. i. 

Aquse Destillat., f^ij. 

Acacise Pulv., 9ij. 

Sacch. Alb., 3^i-—^^- 

A teaspoonful of this mixture to be given every two hours, and an 
enema, consisting of a quarter of a grain of the salt, with mucilage 
and a little opium, to be administered (Eankin's Abst., No. vi, p. 61). 
We have employed this remedy in the proportion of from half a grain 
to a grain in a gill of water, by injection, morning and evening, for 
several days, with very decided benefit, in three cases of diarrhoea fol- 
lowing summer-complaint, in which the stools were frequent, mucous, 
sometimes streaked with blood, and accompanied by tenesmus. We 
have also given it quite frequently internally in mucilaginous solution, 
as above recommended, with excellent results. 

Dr. Woodward (op. cit., p. 264) says, in his article on the treatment 
of the chronic diarrhoea, which was a true entero-colitis, that " by far 
the most valuable local measure is the employment of solutions of the 
mineral astringents as enemata." He mentions sulphate of copper, ni- 
trate of silver, sulphate of zinc, and acetate of lead, but thinks that 
the sulphate of copper and nitrate of silver are probably the most effi- 
cient. The strength he recommends is of one or two grains to the 
ounce of water, of which from one to six ounces may be thrown into 
the rectum two or three times a day. He advises that, when the 
rectum rejects the injection immediately, twenty to forty drops of laud- 
anum be added to each enema, that the injection be thrown carefully 
into the bowel, and the nozzle of the syringe be withdrawn as gently 
as possible, in order that the fluid may be retained at least for some 
little time. We quote these statements, not to induce the use, in chil- 
dren, of solutions of one or two grains to the ounce, but to draw atten- 
tion to one of the means, the ability and advantage of which bore the 
test of the vast army experience in this most severe and troublesome 
disease. In children it is best to begin with a grain to four ounces, 
and, if this gives no pain, or but little, and does not produce the hoped 
for benefit, the proportion may be doubled, or, after two or three trials, 
brought up to that of a grain to an ounce. 

Another excellent remedy in the chronic diarrhoeas of children, one 
from which we have sometimes obtained very satisfactory efi'ects, is the 
syrup of the nitrate of iron. It is given in doses of from two to five drops 
three times a day, in sweetened water, at the age of one or two years. 

The following formula is recommended by Dr. Eustace Smith. AVe 
have used it ourselves in several chronic cases, and have been much 
pleased with its effects : 

R. — Liq. Ferri Pernitrat., f^ss. 

Acid. Nitric. Dil., f^ss. 

Sj-rup. Zinzib., f^j. 

Aq. Anethse, ad fjiij. — M. 

A teaspoonful every six hours at one year of age. 



TREATMENT OF THE CHRONIC FORM. 419 

We have foiiDd a teaspooiifnl every three or four hours not too much 
at three and four years of age. 

Creasote also has been recommended of late years, and is highly 
thought of by some practitioners. It may be given in doses of from a 
quarter to half a drop every three or four hours at a year old. Bouchut 
recommends enemata of from ten to twelve grains of extract o^rhatany, 
or six to ten of tannin, in about five to seven ounces of some vehicle. 

Dr. Pollak, of St. Louis (Trans. Amer. Med. Assoc, vol. viii, p. 260), 
speaks in the highest terms of the efficacy of sulphuric acid in diar- 
rhoea. He thinks that he has succeeded in establishing beyond cavil or 
doubt, " the almost specific effect of sulphuric acid in all cases of diar- 
rhoea. I say in all cases of diarrhoea, and in diarrhoea only, for I hold 
it is less reliable, and even frequently injurious, in dysentery." He says, 
speaking of adults, that "the majority of cases were cured in 24 or 48 
hours; few required the use of it for four days, and only a very small 
number took it as long as eight days; they got nothing else, and were 
cured." He also states he " could successfully prove^ that in the much 
and justly dreaded summer-complaint of children, in cholera infantum, 
it is much preferable to the mercurial, chalk, astringent, and opium 
treatment ; it is even more rapid and more positive in its efi'ects with 
children than with adults." 

The dose he gives to adults is usually half a drachm of the aromatic 
sulphuric acid ever}^ four hours, and he remarks that from four to eight 
doses generally sufficed to effect a cure. His usual formula (for adults) 
is as follows : 

R. — Acid. Sulph. Arom., fjss. 

Tinct. Cardamomi Comp. (or Sp. Lavandulaa 

Comp.), Syrupi Simp., aa, . . . . f^j. — M. 

The dose is printed two tablespoonfids every two hours, but this must 
be an error of the printer; two teaspoonfuls must be the dose intended. 
"If there be tormina, feeble pulse, general prostration, I added aq. 
camphorse, f^j, and gave it in shorter intervals." Dr. Pollak adds, that 
^' the first dose is almost invariably ejected, probably from its suddenly 
astringing the stomach. I then ordered iced water to drink ad libitum, 
in order to soothe and distend mechanically the stomach ; had the dose 
repeated immediately, and have never seen it returned afterwards." 
Dr. Pollak does not inform us of the doses he employs in the case of 
children. We may suppose, however, that for a child of two or three 
years old, half a teaspoonful of the above mixture, and for a younger 
child a yet smaller quantity would be quite enough. 

We have never used sulphuric acid in such large doses as the above, 
but for some years past have been in the habit of employing it in the 
following mixture with excellent results. In cases of diarrhoea, show- 
ing a disposition towards dysentery, as often occurs in entero-colitis, 
and especially when the stomach has been irritable, so as to bear other 
medicinal substances badly, we have found this combination very bene- 
ficial. 



420 ENTERO-COLITIS. 

R.— Acid. Sulph. Arom., gtt. xlviij. 

Tinct. Opii, gtt. xij, vel xxiv. 

Syrup. Kramerige, f^ss. 

Aq. Fluvial, f^ijss.— M. 

A teaspoonful every two hours. 

It should never be forgotten in the treatment of chronic diarrhoea in 
children, that the most important point of all is the regulation of the 
diet and other hygienic conditions. We are fully convinced that we 
have seen several children saved from death by attention to these 
points, and by the persevering and careful employment of tonics and 
stimulants. It often happens, after the disease has lasted for some 
weeks or months, that the powers of the stomach are almost wholly 
lost. The child either refuses food or takes so little that the quantity 
is evidently insufficient to carry on the vital processes, or the greater 
part of what is taken is rejected by vomiting, or lastly, much of it 
passes off through the bowels, and appears in the stools in an undi- 
gested state, forming what is called lientery. If this condition of things 
is allowed to continue, the emaciation and exhaustion make rapid prog- 
ress, and the case must soon terminate fatally. Under these circum- 
stances all the ingenuity and skill of the physician are required to find 
articles of diet of a kind to recall and tempt the child's worn-out and 
often perverted appetite, and which, at the same time, may be digest- 
ible and nutritious, and tend to restore vigor to the digestive function. 
If the stomach is frequently sick, it is best to abandon all remedies but 
those which are stimulating and strengthening, and especially to forbid 
all such as are in the smallest degree nauseous. We would indeed de- 
pend entirely on the use of repeated doses of the oldest and most deli- 
cate brandy that could be found, of which from one to two teaspoonfuls 
may be put into a wineglassful of cold water, and the whole given by 
teaspoonfuls in the twenty-four hours ; or fifteen to twenty drop doses 
of the elixir of Peruvian bark every three or four hours may be used; 
or solution of pepsin, in half teaspoonful doses three times a day; or, 
two or three drops of tincture of nux vomica in sweetened water three 
times a day, if the bitterness does not cause nausea or increase the 
loathing. In such cases, wine of iron, in doses of twenty drops to a 
fourth of a drachm, with syrup of tolu and caraway water, will some- 
times do exceedingly well; or the following, which has sometimes suc- 
ceeded in our hands: 



R.— Tr. Ferri Clilorid., 



Acid. Acet. Dil., 
Liq. Amnion. Acetat., 
Syrup. Simp., . 
Aquse, 

Dose at four years, a teaspoonful, and under that age, half a teaspoonful, three or 
four times a dav. 



f5J- 



f^ss. 
fgij.-M. 



In some very obstinate cases, especially where there is any reason 
to suspect the existence of a malarial element in the case, from half a 



CHOLERA INFANTUM. 421 

minim to one minim of Fowler's solution of arsenic, with the wine of 
iron, three times a day, has been ver3^ serviceable. While this is being 
done, an occasional dose of anodyne, just enough to tranquillize without 
stupefying, may be given. If the rectum will retain it, it is better to 
give it by enema. In some cases we have found the aromatic syrup of 
galls, given with brandy, to be taken by the child without any diffi- 
culty or disgust. 

Exercise by riding, and exposure to the air, which, however, must 
never be carried so far as to induce positive fatigue, are all-important. 
In some very severe and tedious cases, change of residence or travelling 
has been known to effect a cure after all remedies and other means had 
failed. In one case, in this city, which had lasted with but short in- 
tervals for two years, we obtained a perfect cure by persuading the 
parents to send the child into an elevated part of the country in the 
month of ^lay, where it was kept until July, after which it was removed 
to the seaside until the end of August. Nothing was done in the mean- 
time except to regulate the diet most carefully, and to keep the child 
the greater part of the day in the open air. 



ARTICLE III. 

CHOLERA INFANTUM. 

General Eemarks. — In the early editions of this work we failed to 
draw with sufficient clearness the distinction between what we think 
ought exclusively to be called cholera infantum, and the much more 
common disorders which are properly styled simple and inflammatory 
diarrhoea or entero-colitis. In this we did. but follow the practice of 
most American writers, and the custom of the day. Indeed, many 
physicians amongst us are still in the habit of designating the various 
intestinal disorders of children so frequent during the summer heats, 
under the common title of cholera infantum. We believe, on the other 
hand, that a large majority of the deaths registered in our mortality 
returns under this name, are the result not of a true choleraic disease, 
but rather of simple diarrhoea or entero-colitis. We have, however, 
only too often to contend with a disease in children which deserves the 
title of cholera, which is the analogue of cholera morbus, or even of 
epidemic Asiatic cholera, in the adult, and which is the disease we pro- 
i^ose to consider in the present chapter. 

Definition; Synonyms; Frequency. — We can define cholera in- 
fantum only by an enumeration of its most specific characters, and we 
shall do this very much in the words in which Dr. Aitken describes 
epidemic cholera.. Cholera infantum, as we understand it, is charac- 
terized by the occurrence, almost solely during the summer mouths, 



422 CHOLERA INFANTUM. 

in young and generally teething children, who have been pre- 
viously either healthy or the subjects, for a longer or shorter time, of 
simple or inflammatory diarrhoea, of sudden muscular debility, occa- 
sional nausea, spasmodic griping pains in the bowels, depression of the 
functions of respiration, and an appearance of faintness; copious purg- 
ing of thin serous fluid, or of large watery and fetid evacuations, suc- 
ceeded by more or less obstinate vomiting, coldness and dampness of a 
part or of the whole surface of the body, coldness and lividity of the 
lips and tongue, cold breath, a craving thirst, a feeble rapid pulse, diffi- 
cult and oppressed respiration, with extreme restlessness, diminished 
or suppressed urinary secretion, pallor of the entire surface of the body, 
a sunken and pinched countenance, weakness of the cry or partial 
aphonia, and collapse, more or less complete, which may prove fatal, or 
be followed by reaction and a subsequent more or less severe and ob- 
stinate simple or inflammatory diarrhoea. 

This disease is not so common as simple and inflammatory diarrhoea, 
mOvSt cases of which have been hitherto, as stated above, improperly 
grouped under the common name of summer complaint. Though rare 
in Europe, in comparison with its frequency in this country, it is easy 
to recognize from the descriptions, the identity of some of the cases 
called by Billard follicular enteritis, by Barrier ap3^retic and febrile fol- 
licular diacrisis; by Eilliet and Barthez, in their second edition, eholer- 
iform gastro-intestinal catarrh, and by Copland, the choleric fever of 
infants, with the true cholera infantum of America. 

It is impossible to determine its real frequency amongst us, for the 
reason that fatal cases of simple diarrhoea and entero-colitis, are so 
generally included in our mortality returns, with those of the true 
choleraic disease, under the common title of cholera infantum, or sum- 
mer complaint. That it is a frequent cause of death is shown, how- 
ever, by the tables of Dr. Emerson (Am. Jour. Med. Sciences, vol. i, 
1827), wherein it appears that from 1807 to 1827, 3576 deaths from 
cholera, under five years of age, were returned in this city ; of course 
many of these deaths were from a true choleraic disease. This is the 
largest number of deaths from any one disease given in the table. Tine 
next largest item of^ mortality is under the head of convulsions, of 
which it appears that 3192 died in the same period of time. During 
the five years, from 1844 to 1848 inclusive, there occurred in this aitj, 
18,599 deaths from all causes, under fifteen years of age. Of this total, 
1611 died of the so-called cholera infantum, which is the largest num- 
ber of deaths from any one disease, with the exception of convulsions. 
Of convulsions there died 1729. After cholera infantum the largest 
number of deaths was caused by marasmus (1060), dropsy of the brain 
(1041), pneumonia (772), and croup (756). Cholera infantum, there- 
fore, in these tables, causes nearly as many deaths as convulsions 
during the first fifteen years of life, and rather more than twice as 
many as pneumonia. We also refer the reader to the table given at 
pages 386-387, obtained from the Board of Health of this city, exhib- 
iting the mortality under five years of age from cholera infantum, diar- 



CAUSES. 423 

rhoea, and dj'senteiy, with the total mortality at all ages, and with the 
mean temperature of each month. 

Causes. — In discussing the causes of cholera in children, we meet 
again the difficulty so often alluded to, viz., the custom in this country 
of classing in mortality returns, all the deaths from intestinal affections 
in childhood, under the common title of cholera infantum or summer 
complaint. Our own experience leads us to the conviction that the 
causes are the same as those of simple and inflammatory diarrhoea, 
acting with greater intensity. When that cause, or those causes, what- 
ever they may be, act with moderate force, the result will probably be 
a simple or inflammatory diarrhoea. "When, on the contrary, the causes 
are intensified in degree, the case will be apt to take the form of chol- 
eraic disorder. Thus, heat is one of the most influential of these causes. 
So long as the atmospheric temperature is moderate, the resulting dis- 
orders will probably take the form of simple or inflammatory diar- 
rhoea. But let the temperature rise to 85° or 95° Fahr., or even higher, 
as happens occasionally in our summers, and continue at that height 
for three or four days, and children previously well, will be seized with 
the true choleraic forms of diarrhoea, Avhilst those w4ao are already suf- 
fering with simple or inflammatory diarrhoea, are prone to have these 
milder diseases assume suddenly the choleraic type. 

A glance at the table above referred to, shows most plainly the effect 
of heat upon the mortality from bowel diseases in children, under five 
3^ears of age. It will there be seen that, in the two months of July 
and August, when the mean monthly temperature is between 75° and 
80°, the mortality from cholera infantum rises to between two and four 
hundred, and even over; whilst during the cool months, as January, 
February, I^ovember, and Pecember, when the mean monthly temper- 
ature is between 30° and 40° generally", only one, two, three, or none 
at all, are reported. This table shows also, what we have so frequently 
remarked upon, that most of the fatal cases of bowel disease in early 
life, are classed in the medical returns of this city, under the common 
title of cholera infantum, whereas, we are sure from our own personal 
experience, that many of these deaths would be more correctly referred 
to simple or inflammatory diarrhoea, or entero-colitis. Thus, in the 
very months when three and four hundred deaths are grouped under the 
iitle of cholera infantum, only from fifteen to twenty, or a little over, 
appear usually under the term diarrhoea. 

Diet. — Improper diet is another frequent cause of choleraic disease 
in hot weather. Sudden weaning, a change in the character of the ar- 
tificial food, the unfortunate use by accident, or by the carelessness of 
the nurse, of unwholesome milk, of improper vegetables, or, as not un- 
frequently happens, of green or unripe or unhealthy fruit, as apples, 
currants, gooseberries, or blackberries (instances of all of which we 
have ourselves met with), will sometimes bring on in a very few hours, 
the most violent attacks of cholera, or convert a previously mild and 
comparatively safe diarrhoea into the more violent form of disease we 
are considering. These results are especially apt to follow such acci- 



424 CHOLERA INFANTUM. 

dents or imprudences in large cities, where the hygienic conditions are 
always in siiramer of a kind to invite the more violent and dangerous 
forms of intestinal disorder. In fine, the conditions which have been 
ascertained to be most certain to produce epidemic cholera, when that 
disease is present in a locality, are those which develop cholera in chil- 
dren. To put before the reader the conditions most certain to cause 
cholera in children, we cannot do better than to quote from the Beport 
on Epidemic Cholera to the Citizens' Association of Eew York in 1865, the 
localizing causes of cholera. 
These are : 

1. Decaying organic matters, bone, hide, fat and offal houses, neg- 
lected stables, putrescent mud and filth. 

2. Bad drainage, local dampness, malaria. 

3. Obstructed sewers, filthy streets, gutters, stables, garbage, and 
cesspools. 

4. Water and beverages in any manner contaminated by putrescent 
organic matter, particularly by any soakage from privies. 

5. Neglected privies and putrefying excrement. 

6. Overcrowding and neglect of ventilation. 

It is just where these conditions are most rife that choleraic diseases 
in children are most apt to occur. Amongst the poor, who inhabit the 
crowded quarters of cities, where the streets and alleys are small and 
narrow, where heaps of decaying vegetable and organic matters abound, 
where water is scant or scantily used, where ventilation, from the manner 
in which the streets are laid out, and from the crowding together of 
buildings, is necessarily imperfect, we have the most numerous and the 
severest forms of the disease. Add to these the small size of the 
houses, the low ceilings, the small and few windows, and the interior 
arrangement of the rooms, which is such that a thorough draught is 
unattainable, and we need not wonder at the prevalence of the disease. 
It is amongst the poor, too, that the food is often of necessity, as well 
as from ignorance and recklessness, of the most improper kind, and not 
unfrequently, insufficient in quantity. 

But not only the poor, in their unhappy lot, suffer from this disease. 
The children of the rich, with all the advantages of the most whole- 
some hygienic appurtenances which ease and knowledge can supply, 
are apt to contract it if they remain in town during the hot summer 
months. So well is this known, that most families in easy circum- 
stances leave the city for the seaside or the interior, so long as their 
children are young, remaining absent usually from the middle of June 
to the middle or end of September. It is nevertheless true that, whilst 
all the residents in our cities during the summer season are liable to 
see their young children suffer from this disease, those who are so for- 
tunate as to occupy large and airy houses in the best and cleanest 
quarters, and who follow a wise system of hygiene as to diet, water, 
dress, and exposure to fresh air, escape with much more certainty the 
disease than those who are compelled by the necessities of their posi- 
tion to submit to the unhealthy conditions mentioned above. 



ANATOMICAL LESIONS AND PATHOLOGY. 425 

Dentition. — We believe this also to be a most powerful predisposing 
cause of the disease, and yet it would seem to be less influential than 
age, for the tables of Dr. Emerson show that it is about twice as fatal 
in the first year as in the second, though the process of dentition is cer- 
tainly more active and continuous in the second than in the first year. 
We have rarely observed it before the beginning of the process of den- 
tition, and it is certainly very rare after its completion. 

Age, as has just been stated, exerts a strong influence in the produc- 
tion of the disease. In the tables of Dr. Emerson, the cases of cholera 
infantum and cholera morbus are included under the one head of 
cholera, but as all cases of the disease under five years of age are 
called cholera infantum, the want of the distinction does not make the 
statements less useful to us. Erom them it appears that there were 
2122 deaths in the first year, 1186 in the second, and only 268 between 
the second and fifth. Between five and ten years, only 52 cases are 
noted, and these would of course be entitled cholera morbus. In the 
five years, from 1844 to 1848 inclusive, of 1611 deaths from cholera in- 
fantum under 15 years of age, 969 occurred in the first year of life, 
529 in the second, 103 between two and five years, and only 10 after 
that age. 

Sex. — There are no large tables of reference, by which to ascertain 
the exact proportion in which the disease occurs in the opposite sexes. 
It would appear, however, from our own experience, to be much more 
common in males than females, since of 77 cases of which we have kept 
a record, 48 occurred in boys, and only 29 in girls. 

Constitution. — The disease is most apt to occur in feeble, delicate chil- 
dren, and in those of nervous, irritable temperament. 

hereditary Predisposition. — Our own observation leads us to believe 
that the disease is apt to occur in certain families. It would seem 
probable that this peculiarity must depend on the fact that the consti- 
tutions of some families are particularly disposed to disorders of the 
digestive apparatus. We are acquainted with one family in this city, 
in which eight out of ten children, suffered more or less from the dis- 
ease. Again, of these children four have grown up, married, and have 
children. Two of these families have each lost a child from the dis- 
ease; in a third, the two children of the family have been exceedingly 
ill with it ; while in the fourth, some of the children have been sick, 
though not to the same degree. Again, we have attended two children 
in a family, one not quite two years, and the other three months and a 
half old, who have both been very sick with the disease. The elder 
child was ill the summer before in the same way. The mother of these 
children was herself very ill with the disease on several occasions dur- 
ing her infancy, as was also her brother. 

Anatomical Lesions and Pathology. — It will be readily under- 
stood that it is far from an easy task to define precisely what are the 
essential lesions in true cholera infantum, as we have described it. 
Having been confounded so long with ordinary inflammatory diar- 
rhoea, the lesions usually attributed to it are precisely those we have 



426 CHOLERA INFANTUM. 

detailed in our article on the latter affection. In those cases again 
where the true choleraic disease appears during the course of inflamma- 
tory diarrhoea, it is of course difficult to determine to which affection 
the lesions presented after death are in reality due. We must, there- 
fore, seek for the true- and proper lesions of cholera infantum in the 
comparatively rare cases in which this affection has appeared in the 
midst of good health, and has proved fatal during the acute stage. 
With this restriction then, it appears that the only anatomical changes 
w4iich can be regarded as constant and essential to the disease, are en- 
largement of the raucous follicles, and, to a less degree, of the glands of 
Peyer; and softening, and in some cases erythematous inflammation of 
the mucous membrane. 

There can be little doubt that the appearances thus indicated, de- 
pend upon the presence of an early stage of inflammation of the tissues 
of the intestinal walls, and of the mucous follicles. This view is sup- 
ported by the similarity between these lesions and those found in cases 
of entero-colitis, proving fatal during the early stage, as well as by the 
fact that where the child survives the choleraic stage, and ultimately 
dies after a continuance of diarrhoea for some days, or even several 
weeks, the lesions are found to have developed into those ordinarily 
found in primary entero-colitis. 

It is, however, necessary to consider briefly what additional element 
is present, in this form of disease, which impresses upon it such pecu- 
liar and fatal features; or, in other words, what is the pathology of the 
collapse which characterizes cholera infantum. 

It is a matter of much regret, that as yet we are wanting in careful 
microscopical examinations of the condition of the epithelium of the 
mucous membrane, and of the characters of the evacuations. We 
should anticipate, however, from the evident similarity between 
cholera infantum and sporadic cholera, ©r cholera morbus in the adult, 
that in the former as in the latter disease, such examination would, 
reveal rapid proliferation and exfoliation of the cells of the mucous 
membrane. 

In regard to the explanation of these lesions, we would refer the 
reader to the remarks upon the pathology of entero-colitis, where we 
have expressed our belief that the causes of these affections (heat, 
noxious emanations, unwholesome food), act in a complicated manner, 
by inducing a state of mal-nutrition in which the tissues are prone to 
undergo inflammatorj^ changes, by loading the blood with noxious sub- 
stances, which may irritate the glands which excrete them, and finally 
by interfering with digestion, so that the contents of the intestinal 
canal undergo changes which render them highly irritating. 

We repeat that we recognize in cholera infantum the presence of the 
general alteration of nutrition, and the change in the entire blood-mass, 
as well as the local irritant action of the morbid contents of the intes- 
tines. But it is in the highest degree interesting and significant of the 
importance of this last element in the causation, that symptoms alto- 
gether indistinguishable from those of cholera collapse, may be produced 



ANATOMICAL LESIONS AND PATHOLOGY. 427 

by agencies acting directly and solely upon the coats of the stomach 
and intestines. 

Attention has been lately directed to these analogous conditions by 
Sedgwick, in a highly valuable article, " On some Analogies of Cholera^ 
in which suppression of urine is not accompanied by symptoms of urcemic 
poisoning" (3Ied.-Chir. Trans., yo]. li, p. 1, 1868), in which he has col- 
lected many such examples. Among the causes which are clearly estab- 
lished as capable of producing such an analogous condition, are poison- 
ous doses of corrosive sublimate, arsenic, some of the mineral acids, 
especially nitric acid; and also of certain drastic purgatives, especially 
croton oil. In these cases the peculiar symptoms produced, which are 
uniformly described by accurate observers as most closely analogous to 
those of cholera collapse, are due exclusively to the direct irritant action 
of the substance upon the gastro-intestinal mucous membrane. 

The same effects have frequently been observed to follow the eating 
or drinking of poisonous animal matters, such as tainted or simply un- 
wholesome meat or fish, and milk which has undergone some injurious, 
but as yet unknown change, decomposing vegetables, and some of the 
poisonous fungi. In this last group of cases, the local irritant action 
of the substances swallowed, must certainly be regarded as the principal 
cause in the production of the symptoms, although it is quite possible 
that the ingestion of such putrid animal or vegetable substances should 
also cause an altered condition of the blood. 

In like manner, there are numerous morbid conditions of the intestines, 
or their peritoneal covering (as perforation with subsequent periton- 
itis, peritonitis from extension of inflammation, intestinal obstruction), 
which may be attended with symptoms closely analogous to those of 
cholera collapse. 

We will also quote from Eilliet and Barthez, the following passage in 
regard to the remarkable memoirs upon Inanition, by Dr. Chossat, of 
Geneva, which show the analogy which exists between the results of 
experimental inanition and the chief symptoms of cholera infantum. 
"This is seen especially (1.) In the diminution of temperature, which 
conjoined with the loss of weight, is in inanition, as in cholera infantum: 
one of the principal causes of death. (2.) In the stupor which follows the 
jactitation as the temperature falls. (3.) In the colliquative diarrhoea 
during the last few days of life, the severity of which is proportioned 
to the rapidity of the fatal termination, and to the increase of the 
algidity." 

It is not within the scope of the present work to discuss, critically, 
the various theories which have been advanced to explain the modus 
operandi of such causes in producing a state of collapse analogous to 
that of cholera, as well as the pathology of true cholera collapse. 

It is, however, evident, that the mere drain of fluid from the alimen- 
tary canal, although it undoubtedly has much influence upon the course 
of the disease, cannot be regarded as the efficient cause of collapse, 
since in many cases profound collapse occurs with comparativel}' scanty 
discharges. 



428 CHOLERA INFANTUM. 

So too we must regard Dr. Johnson's hypothesis {Medico- Chir. Trans. ^ 
vol. li, 1867, p. 108. et seq.), that the symptoms of collapse are due to a 
spasm of the minute branches of the pulmonary artery, caused by the 
specific alteration of the blood in cholera, as based upon insufficient ar- 
guments. Thus, in the first place, we have cited instances above where 
symptoms altogether similar to those of cholera collapse, are produced 
under circumstances in which it is impossible even to suspect the exist- 
ence of a poisoned state of the blood. Again, there is neither any 
clinical nor anatomical evidence to show that the contraction of the pul- 
monary artery is relatively greater than that of the rest of the arterial 
system ; or again, that such contraction precedes the other signs of col- 
lapse. 

In the last edition of this work, we quoted the opinion of Eilliet and 
Barthez in regard to the implication of the sympathetic nervous sys- 
tem in cholera infantum, and since that time we have been led to regard 
this more and more strongly as the essential cause of the collapse which 
characterizes this and other choleraic conditions. 

The passage extracted from the admirable work of Eilliet and Bar- 
thez was as follows : " The disease we have just described is, in our opin- 
ion^ a catarrh which has localized itself upon the digestive tube and the 
great sympathetic nerve. It is, of all forms of the catarrhal affection, 
that which most clearly justifies the idea of a poisoning. It proves also 
that anatomical dift'erences alone will not suffice to establish a separa- 
tion between the various species of the disease. 

" Its catarrhal nature is demonstrated by the causes, which are those 
of all catarrhs (improper alimentation, epidemic influence, &c.) ; by the 
analogy of the symptoms; by the gradual passage of the mild into the 
grave forms, through intermediate cases; and lastly, by the fact that 
simple intestinal catarrh is often but the prodrome of choleriform enter- 
itis. 

''Eeasoning from the simple fact that the disease is catarrhal, we ad- 
mit the existence of a modification of the whole economy, and of some 
alteration of the blood. 

" A study of the anatomico-pathological descriptions of the disease, 
and especially the observation of cases, demonstrates that the gastro- 
intestinal tube of children dying of this affection may be found in four 
different conditions: 

"a. Either the stomach is softened without any lesion of the diges- 
tive tube. 

^^ b. Or the stomach is softened, at the same time that the mucous 
membrane of the intestines, and especially its follicular apparatus, is dis- 
eased. 

" c. Or the stomach is healthy, whilst the follicular apparatus or the 
mucous membrane are diseased. 

"^. Or, lastly, the gastro-intestinal tube fails to exhibit any lesions 
appreciable by our senses in the present state of our knowledge, or it 
presents alterations too insignificant to explain the gravity of the symp- 
toms." 



ANATOMICAL LESIONS AND PATHOLOGY. 429 

.... ''Up to this point the disease resembles all other catarrhs, but 
what gives to it a special type is the abundance of the serous secre- 
tions and the disturbance of the great S3'mpathetic nerve. 

'•The serous secretion, which seems to be produced by perspiration 
(analogous to that of the respiratory passages and of the skin), rather 
than by a follicular secretion, shows, perhaps, that the elimination of 
morbid matter is accomplished by other organs than the follicles; and 
we ought perhaps, to see in this a proof that the matters to be eliminated 
are not the same as in simple catarrh. On all these points we are 
compelled to remain in doubt; we content ourselves with stating the 
fact. 

"The functional derangements of the trisplanchnic nerve play an 
important part in the disease; under this point of view it differs from 
the mild form, in which the innervation is normal, and from the cere- 
bral form, in which it is especially the cerebro-spinal apparatus that is 
sympathetically affected. The proof of a disturbance of the ganglionic 
nervous system, rests upon the following physiological and nosological 
considerations: 

"The disease exists at the age and in the physiological condition 
(dentition), in which functional derangements of the nervous system 
without lesions of organs are most frequent; it is often complicated 
with those very disorders of the general innervation, as is proved by 
certain profound changes in the functions of nutrition, circulation, and 
calorification, which the amount of material waste will not always 
account for. We occasionally observe the same symptoms of nervous 
sideration, and particularly the extreme smallness of the pulse^ and 
the algid phenomena, to arise in certain of the most violent attacks of 
spontaneous peritonitis. Now these phenomena, which cannot always 
be referred to the intensity of the pain, and which do not exist in in- 
flammations of the other serous membranes, no matter what the rap- 
idity of their course, are only to be explained by the fact that the dis- 
ease, seated in the abdomen, envelops the ganglia of the great sympa- 
thetic nerve." 

Since the date at which this was written, our knowledge of the func- 
tions of the sympathetic nerve, especially with regard to its power of 
regulating the calibre of the arteries, by inducing contraction or allow- 
ing relaxation of their muscular coat, has been much advanced; and 
we are fully prepared to understand how the symptoms of cholera col- 
lapse might be explained upon the supposition of a widespread power- 
ful irritation of the fibres of the sympathetic nerve, so richly distributed 
to the coats of the vessels throughout the alimentary canal, and which 
have such intimate relations with the nervous supply of the whole 
arterial system, as well as of the heart and lungs. 

Thus we can most readily explain in this way, the small, thready 
pulse; the cold, pale, and shrunken skin; the asphyxia and coldness of 
the breath; the diminution in the formation of urea and in the secre- 
tion of urine. 

The above views of the pathology of choleraic collapse, have been of 



430 CHOLERA INFANTUM. 

late ably supported b}^ Sedgwick (loc. cit.), and Dr. Horace Jeaffreson 
(Edin. Med. Jour., December, 1866, p. 520). 

At the same time, the probability is that the vaso-motor nerves of 
the intestinal walls themselves are paralyzed, from exhaustion of their 
excitability, so that dilatation of the vessels occurs with profuse dis- 
charge of serum. 

So far as experimental research can be made available in deciding 
questions involving such deepseated and delicate parts, the results en- 
tirely confirm the explanation given above. Thus Moreau^ has found 
that, after section of the branches of the sympathetic nerve suppljnng 
the intestines, a copious secretion of alkaline serous fluid takes place 
into the bowel. 

Symptoms. — Eestricting, as we now do, the term cholera infantum to 
cases which have a truly choleraic character, we shall have a smaller 
ground to go over than w^e had in our early editions. 

The invasion of the choleraic symptoms is sudden. The child may 
have been quite well previously, or may have been the subject for an 
indefinite length of time — days or weeks — of simple or inflammatory 
diarrhoea, when, from exposure to high summer heats (85° to 95° Fahr.) 
in a city, or more rarely, in the country; from being allowed to take 
some unwholesome article of food; from the efl'ort of cutting teeth; or 
perhaps from having been chilled by night air, or by a sudden change 
of the weather from hot to cool; the choleraic disorder breaks out, with 
almost simultaneous vomiting and purging. The diarrhoea is, fyom the 
beginning, violent. The stools are usually frequent, consisting almost 
entirely of a thin fluid, which runs through the napkins and wets the 
clothes of the child. Sometimes the discharges are not verj^ frequent, 
but each one may be so large as to wet not only the napkins and clothes 
of the child, but to run through to the lap or bed on which the patient 
lies. The chief and important characters of the stools in true cholera 
infantum, as in cholera of the adult, are their fluidity and quantity. 
These two characters, more than the vomiting or the nature of the dis- 
charges in any other respect, are the special signs of the disease, and 
by the degree in which they are present do we recognize the disease, 
and usually determine its severity. The fluid thus rendered by stool 
may be of diff"erent characters. It may be an almost colorless liquid, 
merely wetting the napkins and clothing, as though they had been 
dipped into a bucket of water, or saturated with the pale urine of a 
healthy infant; or they may consist of the same watery fluid, holding 
in suspension small and soft flocculi of fecal matter of a yellowish or 
greenish color, or small detached portions of mucus, which are left upon 
the napkins as the watery fluid drains through them. When the stools 
are of this kind, the}^ are usually almost inodorous. In other cases, 
they are still very water}?-, but the fluid is yellowish or brownish in 
color, contains rather a larger amount of thin feculent matter, and has 
a most off'ensive odor, — an odor which is peculiar for its extreme fetidity, 

1 Comp. Rend, de I'Acad. des Sciences, t. Ixvi, p. 554, 1868, in Medical Times and 
Gaz., April 11th, 1868, p. 397. 



SYMPTOMS. 431 

a fetidity so great that we have known it to cause vomiting in those 
exposed to it, and so adhesive as to render it necessary to change at 
once all the clothing and bed-linen of the child, and even then the fetor 
may cling to the body of the patient, after repeated washings. This 
odor we have seldom met with except in the choleraic form of summer 
diarrhoea. The number of the stools varies greatly. We have known 
as many as twelve to be passed in as many hours. In other cases they 
are not so frequent, but the quantity at each time may be so great as to 
drain the body of its fluids at a more rapid rate than many more evacua- 
tions of an ordinary size. Eight, twelve, fifteen, or more than twenty 
stools in twenty-four hours are not rare. In one fatal case, in a child be- 
tween one and two years old, there were between twenty-five and thirty 
stools during the second night of the attack, in a space of twelve hours. 

Simultaneously with, or soon after the diarrhoea sets in, there is 
vomiting. The matters vomited consist at first of the ordinary con- 
tents of the stomach, foOd, and water. Soon these matters consist of 
the water or medicines that may be taken, and of a serous or sero- 
mucous fluid mixed with small portions of bilious matter. Sometimes 
they are tinted green as so often happens in the gastro-intestinal affec- 
tions of children. The vomiting may or may not be very frequent. 
Sometimes it is one of the severest elements of the disease, causing 
everything taken to be rejected almost as soon as swallowed, or assum- 
ing the form of repeated and exhausting retching, even when the stom- 
ach is quite empty. In connection with these symptoms there is rapid 
loss of strength. The child is listless and still between the evacuations 
and vomiting, or tosses and moans with the jactitation of severe illness. 
The appetite is lost, but thirst is extreme, and constitutes one of the 
marked phenomena of the disease. Water and ice are seized upon with 
the greatest avidity, and taken almost incessantly, if allowed, though 
rejected only a few moments afterwards. 

The abdomen is flaccid or retracted, not tender to the touch usu- 
ally, and the walls inelastic^ so that they can be readily pinched up 
into folds. The tongue, moist at first, with a thin white far upon it, 
becomes pasty or dryish after a time, and is sometimes protruded from 
time to time between the lips. 

The pulse runs up from the first, rising soon to 130, 140, and 150, and 
being usually small in volume, whilst the temperature remains for a 
time normal, rises slightly above the natural point, or, in some few 
cases, the skin becomes hot. The urine diminishes in all these cases, 
and in very severe ones, ceases to flow, or flows only in the smallest 
quantities. As in true cholera, the degree of suppression of this func- 
tion is in proportion to the severity of the choleraic discharges. The 
respiration, natural at first, soon becomes, if the case goes on unfavor- 
ably, irregular, unequal, and anxious. The temper is irritable at the 
beginning, the child being restless, peevish, disposed to fret and cry at 
the least contradiction or disturbance. The sleep is restless and dis- 
turbed, especially at night. The child wakes frequently, and almost 
always with crying. When asleep, the eyes are often but half closed, 



432 CHOLERA INFANTUM. 

and the brow contracted and frowning. The countenance soon becomes 
anxious and distressed. In sudden and severe attacks^ it is languid 
and subdued, pale and contracted. 

If the disease is not soon checked, signs of collapse make their ap- 
pearance, and become more and more marked features. The body 
becomes cool and then cold, the pulse grows smaller, thready, and very 
rapid; the features are drawn; the nose is sharp and thin; the eyes 
shrink within the orbits; the cheeks become sunken; the patient 
passes into a still, quiet, and drowsy state; the vomiting may cease, 
but' the diarrhoea usually persists ; the child falls into a comatose or 
semi-comatose state, and death occurs quietly in this condition, or may 
be preceded by slight convulsive movements. According to the re- 
searches of Eoger {op. cit.. p. 399), the reduction in the temperature of 
the axilla never approaches, in these cases of sporadic cholera, that 
which is found in cases of the true epidemic form occurring in children. 
Some very violent cases run their course in a day, a day and a half, or 
two or three days. We, ourselves, do not recollect to have seen any 
case terminate sooner than in three days and a half. 

In favorable cases, after one, two, or three days, the diarrhoea ceases 
to be so violent; the stools grow less frequent, smaller in quantity, 
thicker in consistence, containing a better concocted fecal matter, and 
regaining a more natural odor. The vomiting and thirst gradually 
subside; food is again taken and retained; the circulation falls, and 
the child, though weak and thin, and the subject for some days of a 
simple diarrhoea, may regain its health in great measure, at the end of 
a week or ten days. More frequently, however, the disease assumes 
the form of a more obstinate simple or inflammatory diarrhoea, which 
may last for several weeks, to take on again, perhaps, from a recur- 
rence of the exciting causes, the choleraic form, or to persist in one of 
the former shapes until the return of cool weather. 

Such is a picture of the disorder to which we think the name of 
cholera infantum ought to be restricted. If physicians could agree to 
limit the title to this true choleraic disease, our mortality returns would 
soon show the comparative frequency of death from this disorder, and 
from those more tedious and chronic diseases which have already been 
treated of under the designation of simple and inflammatory diarrhoea 
or entero-colitis. 

The duration of cholera infantum, as we restrict the term, is seldom 
more than two, three, or four days. It may prove fatal in a much 
shorter time. Dr. Eberle {Dis. of Children, p. 285) says it sometimes 
runs on to a fatal termination in five or six hours. Dr. J. Lewis Smith 
{op. cit., p. 392) reports a case in a child sixteen months old, which 
ended fatally in less than one day; a second, at seven months, after a 
sickness of about one day; and a third, at twent}' months, in thirty-six 
hours. We do not recollect, in our own experience, which has been 
chiefly in private practice, a shorter case than one of three days and 
a half In favorable cases the diarrhoea usually persists, as already 
stated, for several days after the disappearance of the choleraic phe- 



DIAGNOSIS — PROGNOSIS. 433 

nomena, and very frequently runs on into a simple or inflammatory 
diarrhcea, which follows the law of those disorders. 

Diagnosis. — The diagnosis of cholera infantum requires no particular 
elucidation. The season at which it is most prevalent ; the profuse, 
serous, or at least fluid evacuations ; the frequent and severe vomiting; 
the early exhaustion of muscular strength; the rapid pulse, with ab- 
sence of, or a very moderate febrile heat; the threatening or the actual 
supervention of collapse, marked by cool or cold surface, pinched and 
anxious countenance, shrivelled skin, sighing or irregular respiration, 
rapid and feeble or extinguished pulse, diminished or suppressed urin- 
ary secretion; with, finally, the still and limp body, and drowsy or 
comatose brain, all mark a disorder which is readily recognized after 
being once seen, or which may be distinguished by any intelligent per- 
son who has never 3'et met with such a case, if onl}^ the progression of 
the symptoms be carefully inquired into, and correlated with the 
present condition. 

Prognosis. — Cholera infantum, as w^e restrict the use of the term, is, 
of course, always a dangerous disease. Collapse, which either threatens 
all who are attacked by it, or actually supervenes to a greater or less 
degree, is well known by all phj-sicians to be one of the most formid- 
able morbid conditions to which the body is liable. The degree of 
danger in any individual case must depend chiefly upon the ability of 
the physician to arrest, and of the patient to resist, this state. The 
probability of the supervention of collapse depends very much upon the 
hygienic condition in which the child is placed, upon the age of the 
patient, the stage of the process of dentition, the present state of health, 
the innate vigor of the constitutional force, and also, we may say, upon 
the period of the disease and the degree of wisdom with which medical 
means are ap])lied. Children placed in favorable hygienic contlitions 
in the country, or in the healthier parts of cities, in large and well-ven- 
tilated rooms, and who have been fed upon proper diet, and who have 
therefore been attacked by the disease whilst in previous fair health, 
are much more apt to escape collapse, or to recover from it after it has 
made its appearance in a more or less marked degree, than those who 
are placed in conditions the opposite of those we have enumerated. 
Early age, recent weaning, improper artificial diet, and feeble vital 
powers from an}^ cause, either inherent or acquired, are amongst the 
most unfavorable prognostics. Still, we should never despair until the 
last moment, since we have seen some most surprising recoveries from 
apparently desperate conditions in this disease. 

The prognosis may be stated in general terms to be unfavorable in 
proportion to the frequency and violence of the vomiting, the number 
of the stools, the severity of the fever, and the more or less marked 
character of the collapse. When the discharges consist merely of 
serous fluid, and are copious and frequent; when they consist of small 
quantities of deep green matter, mixed with much mucus or with blood ; 
when accompanied by straining; when they number from fifteen to 
twenty-five in the day; when they are very fetid; and when, with 

28 



434 CHOLERA INFANTUM. 

these symptoms, the abdomen is tense and tympanitic, the countenance 
pinched, the expression languid, the extremities cool, the pulse rapid 
and small, and the child irritable and restless, or, on the other hand, 
very still and subdued, the prognosis is exceedingly bad. If, after the 
symptoms just enumerated, drowsiness or stupor, and then coma, con- 
vulsions, rigidity, or paralysis make their appearance, there is scarcely 
a hope left. 

The favorable symptoms in any case are, diminution of the fever; 
equal temperature of the whole surface; cessation of vomiting; de- 
crease in the number of the stools, and a return to their natural color, 
consistence, and odor; quiet, tranquil sleep; return of appetite; and 
lastly, a restoration of the natural temper and gayety of the child. 

Prophylactic Treatment. — The danger to which teething children 
are exposed from residence in this city during the hot months of the 
year, is now so well understood that most fjimilies who can afford it 
remove to the country during the warm season, and by this course 
very generally avoid the disease. It is undoubtedly the best plan that 
can be adopted, and very commonly succeeds. When this cannot be 
done, however, the proph^'lactic treatment consists in a most careful 
attention to diet, dress, and exposure to the open air. If possible, the 
child should be kept at the breast until it has passed through its second 
summer, as there is but little danger from the disease after that period. 
If the weaning must take place prior to that age, it ought to be accom- 
plished before the hot w^eather begins, as a change from the breast to 
artificial food during the warm season is very apt to bring on the dis- 
ease. If the child is weaned, the diet must be strictly attended to. 
Up to the age of ten months or a year, the food should consist almost 
wholly of milk containing arrowroot, rice, oatmeal, or some farinaceous 
substance in small quantity. A little plain chicken or mutton water, 
with rice boiled in it, or a piece of beef or chicken to suck, may be 
given occasionally, but all vegetables and fruits should be strictly for- 
bidden. After the age of ten months, some light soup and small por- 
tions of muiton, chicken, or very tender beef, minced very fine, may be 
given every day in addition to the milk food, which must still form the 
major part of the child's nutriment. Fruit of all kinds, all vegetables 
except rice and potatoes, and the latter are doubtful, ought to be care- 
full}^ avoided until after the hot season has passed entirely away, or 
until the child has its full set of teeth. We have found the food pre- 
pared with gelatin, in the manner described at page 338, to answer 
better than anything else for a large number of children to whom we 
have prescribed it. 

The dress ought to be arranged according to the heat of the day. It 
is the fashion in this city to keep young children clothed all summer in 
thick flannel jackets, and petticoats, and woollen socks. This is cer- 
tainly too much for the hot days which so frequently occur in July, 
August, and early in September, and is often, we believe, very injurious. 
A light gauze flannel shirt is the only woollen garment that need be 
worn during the warm season. On hot days a child should have only 



TREATMENT. 435 

this, a muslin petticoat and frock, and the lightest possible socks, or 
none at all. If, as constantly happens in our climate, a cool day comes, 
there should be added to these a light flannel petticoat. 

It is of the utmost importance that children should pass as large a 
portion of the day as possible in the open air. In the country this is 
easily managed, and parents almost always contrive to accomplish it; 
but in a city, many people seem to think it of less importance, or their 
servants are occupied with other things, and it is neglected. It is 
nevertheless a matter of the greatest consequence ; the child ought to 
be kept in the air by the nurse for several hours in the morning and 
evening, either in the garden attached to the house, if there be one, at 
the front door, walkiiig in shady streets or public squares, or, better 
still, making short excursions into the neighboring country, taking 
care, however, to avoid the intense heat of the sun during the middle 
of the day. 

We believe that with constant and wise attention to these points, 
viz., diet, dress, exposure to the air, and exercise, much may be done 
towards preventing the disease even in families obliged to remain in 
the city daring the summer. 

As stated in the account of the symptoms, the choleraic disease often 
suj^ervenes in children who have already been the subjects of simple or 
inflammatory diarrhoea. When, therefore, a child in the city has diar- 
rhoea, if it do not yield readily to treatment, and especially if the stools 
begin to be thin and watery, with any marked tendency to exhaustion, 
it ought to be regarded as being threatened w^ith cholera. In such an 
event, the best prophj^laxis in the world is instant removal to some 
high country locality or the seaside. 

Treatment of the Attack. — Regarding this disease as a truly chol- 
eraic one. w^e shall follow^, in the consideration of its treatment, the plan 
adopted by some of the more recent writers on Asiatic cholera; and 
shall accoi-dingly divide our discussion of this subject into the treat- 
ment appropriate for the three stages of evacuation^ collapse^ and re- 
action. 

Every young child who is attacked with diarrhoea, whether simple 
or inflammatory, in the summer season, ought to be regarded as liable 
to cholera, and should be carefully watched to prevent the development 
of this disease. For the proper treatment of such conditions, the reader 
is referred to the article on those afl'ections. 

Should a child, either previously w^ell, or the subject of diarrhoea of 
the ordinary form, be attacked with sudden, profuse, frequent, and 
waterj" discharges, and especially, should these be associated wMth vom- 
iting, with spasmodic intestinal pain, and with any appearance of gen- 
eral exhaustion, it ought to be presumed to be in the early or evacuation 
stage of cholera infantum, or in what is the analogue of the evacuation 
stage of epidemic cholera. Under these circumstances, it has been a 
prevalent practice here to give a cathartic, castor oil, calomel, or rhu- 
barb. We think the practice wa'ong, unless there be positive evidence 
that the attack has followed directly upon the use of some un whole- 



436 CHOLERA INFANTUM. 

some article of diet. If it be found that the child has certainly eaten 
some such food, green apples, currants, gooseberries, or articles of this 
kind, and that these have not come away in the discharges, it is right 
to give first a moderate purgative. We prefer castor oil or syrup of 
rhubarb, half a teaspoonful of the former, or a teaspoonful of the latter, 
with two drops of laudanum at the age of one year, or a teaspoonful 
of castor oil, or two of the syrup of rhubarb, with four drops of lauda- 
num at two or three years of age. Two hours after this dose, if the 
stools continue frequent and watery, we use the chalk mixture, with 
tincture of krameria and laudanum or paregoric (a teaspoonful of the 
chalk mixture with ten to fifteen drops of the krameria, and one drop 
of laudanum, or five of paregoric) every two hours at the age of one 
year. Thirty drops of the syrup of nutgalls (see article on entero-coli- 
tis), with an opiate every two hours, is often very useful. We believe 
that the great object is to arrest the watery discharges by stool. If 
the above means fail, laudanum may be given by injection, and two 
drops at one year, and double the dose at two years, every two or three 
hours, may be tried in addition to the above treatment. The quantity 
of opium must depend on its effects. Children, like adults, bear very 
different amounts. As soon as positive drowsiness appears, or the pupils 
become contracted much below their natural size, the doses must be sus- 
pended or diminished, or the intervals between them lengthened. Of 
course, if the stools lessen in frequency, quantity, or fluidity, the san:e 
reduction in the amount of the opium ought to be made. 

When vomiting is severe and frequent, and the above remedies are 
rejected, we may use the one proposed in the article on inflammatory 
diarrhoea, consisting of solution of morphia, dilute sulphuric acid, and 
cura^oa cordial. This, or some similar remedy, is at times very suc- 
cessful. It is nineteen years since one of us saw a child nine months 
old, in deep collapse from a most violent attack of cholera infantum, 
who rejected its mother's milk as though it had been tartar emetic, 
whose stomach was only made worse by calomel, but who began to 
improve very soon upon doses consisting of two drops of aromatic sul- 
phuric acid, and five drops of solution of morphia, in a teaspoonful of 
iced water, every hour. Since then we have frequently used the, mix- 
ture above recommended in such cases, and we think, on the wiiolc, 
WMth more control over the vomiting than anything else we have tried. 

The experience gained by careful and lengthened observation in the 
treatment of the evacuation stage of Asiatic cholera, may well be ap- 
plied to the aflection under consideration, so much alike are they. Dr. 
Goodeve (loc. cit., p. 177) gives first a full dose of opium (he says that 
calomel was gencrall}^ combined with it in India, and though he does 
not "know that the calomel does good, it does no harm"), to an adult 
two grains, and half an hour afterwards he begins with an astringent, 
in his own practice, usually the following mixture: 

R. — Plumbi Acetat., . . . gr. xxx. 
Acid. Acet., . . . . ttj^x. 
Aq. Destillat., .... f^vj.— M. et ft. sol. 

One ounce or half an ounce every half hour or hour. 



TREATMENT. 437 

At the end of an hour from the administration of the first dose of 
opium, if the purging persisted, lie gave one grain of opium and con- 
tinued the astringent. A small teaspoonfiil, or two-thirds of an ordi- 
nary teaspoonful of this solution would contain about half a grain of 
the acetate of lead, and this might safely he given to a child a year old 
for several doses. We have not used this remedy ourselves, but it 
comes from a source which commends itself to us, and we shall not 
hesitate to use it when the occasion presents itself. As soon as the 
frequency of the discharges is arrested, the doses should be given at 
longer intervals, and when the peculiar serous character of the stools 
has disappeared, this remed}' ought to be suspended, and some more 
simple one substituted, in order to avoid the possibility of pi'oducing the 
toxic action of lead. 

If, in s})ite of the treatment, the stage of collapse should set in, other 
methods of treatment must be adopted. Here the stools are usually in 
great measure arrested, or thej' are few in number and small in amount. 
The object to be sought after is to produce reaction, or rather to favor 
the efforts of nature to bring about this change. It is now generally 
acknowledged hymen of large experience, that the old plan of pouring 
in large doses of opium and alcohol is a great mistake. But little is 
absorbed by the stomach whilst the body is in this condition, and not 
unfrequently the patient is injured, perhaps fatally, by the sudden ab^ 
sorption of these substances, when the stomach begins to act after reaCr 
tion has taken place. The opium may cause dangerous or fatal stupor, 
or may increase or keep up the tendency to suspension of the urinary 
function, and thus promote one of the great dangers of the disease, 
ursemic intoxication. The alcohol, if it has been used in large quanti- 
ties, would also tend to clog the nervous centres, to cause gastric or 
gastro-intestinal catarrh, and to heighten beyond a safe point the febrile 
movement which is so apt to accompany the reaction stage. Oj)ium, 
therefore, should be avoided during collapse, or given only in the smallest 
doses. Alcohol, though it should never be given in large doses, and 
recklessl}", as has so often been done, may be used in small quantities, 
especiallj^ if it be found by close watching, that it promotes the force 
and volume of the pulse. Ten or fifteen drop doses of old and delicate 
brandy, in a teaspoonful or tablespoonful of ice-water, may be given 
ever}^ hour or two hours, at one year of age. During collapse the 
stomach is still often very irritable, and yet the thirst continues intense. 
"We are glad to find that such men as Drs. Maclean and Goodeve recom- 
mend the free use of ice and water under these circumstances. Our own 
practice, for years past, has been to allow ice and cold water, almost with- 
out limit, to children in this condition, and we are much pleased to know 
that such, too, is the practice of these gentlemen. We never could under- 
stand the wisdom of refusing water to patients who were suffering the 
horrid thirst produced by the immense losses of the water of the body 
by serous purging. The degree of thirst for water (a natural and not 
a secondary diseased instinct, like that of the drunkard for alcohol) must 
be the safest guide we can have as to the need of the body for water, 



438 CHOLERA INFANTUM. 

and as such, it ought always, it seems to us, to be gratified, unless under 
very rare and most peculiar conditions. We give water and ice, even 
though the child vomits from time to time, believing and hoping that 
some will be absorbed to take the place in the tissues of that which has 
been drained off through the intestines. This point in the treatment 
we regard as so important, and one, we think, so much misunderstood by 
the public and by some medical men, that we make the following quo- 
tation from a note of Professor Maclean's to Dr. Aitken (Aitken's Prac- 
tice, vol. i, footnote, page 663) : "Urgent thirst is one of the most dis- 
tressing symptoms in cholera; there is incessant craving for cold water, 
doubtless instinctive, to correct the inspis-ated condition of the blood, 
due to the so rapid escape of the liqiioj^ sanguinis. It was formerly the 
practice to withhold water — a practice as cruel as it is mischievous. 
Water in abundance, pure and cold, should be given to the patient, and 
he should be encouraged to drink it, even should a large portion of it 
be rejected by the stomach ; and when the purging has ceased, some 
may with advantage be thrown into the bowel from time to time.'^ 
The use of water by enema, when the diarrhoea is checked, is a point 
which ought not to be neglected, especially if the stomach continues 
weak and irritable. A gill of tepid water may be used at a time, thrown 
slowly and gently into the bowel, in the case of a child one or two years 
old. If this is retained well, the same quantity may be repeated in one 
or two hours. 

AVhilst the collapse lasts, but little food can be taken. It is seldom 
retained if used in anj^ quantitj', and the stomach has lost, in great 
measure, its digestive pow«r. The only food we have found at all avail- 
able has been thin chicken tea, Liebig's cold extract of beef, or weak 
wine-whey, given in two or three teaspoonful doses, every half hour or 
hour. It is worse than useless to attempt more than this, as not only is 
it not retained, but it evidently tends to keep up the nausea and vomit- 
ing, and thus retard the natural effort at reaction. As to remedies in 
this condition, we doubt whether anything better can be done than to 
use water, as just advised, and small doses of brandy, and, if they can 
be borne, small quantities of the liquor ammonias acetatis, ten to twenty 
drops, in cold water, every hour, at one year of age. There is, however, 
a remedy which has obtained a great reputation amongst the English 
arm}' surgeons in India, for the promotion of reaction in the collapse 
stage of epidemic cholera, which we have used ourselves with advantage 
in adults, but not in children, though we propose trying it when we 
next have a good opportunity. It is spoken highly of by Dr. Maclean. 
The formula is as follows: 

R.— 01. Anisi, 01. Cajeput, 01. Juniper., aa, . . f^ss. 

^ther., f^ss. 

Liq. Acid. Hulleri, f^ss. 

Tinct. Cinnamom., f^ij. — M. 

The dose for an adult is ten drops every quarter of an hour, in a tablespoonful of 
water. 

An opiate may be given with the first and second doses, but should 



TREATMENT. 439 

not be continued, for the reasons already given. The liq. acid. Halleri 
consists of one part of concentrated sulphuric acid to three parts of rec- 
tified spirit. The dose of this mixture for a child a year old, ought, we 
think, to be about one or two drops in a teaspoonful of water, given, as 
above stated, every quarter of an hour. So much is this valued in India, 
according to Dr. Maclean, that it is always ordered to be kept in store 
in the "medical field companion" of armies on the marcli. 

It must not be supposed that all children seized with choleraic diar- 
rhoea are necessarih' to pass through the collapse stage in all its terrors. 
On the contrary, many, when judiciously treated early in the disorder, 
escape collapse altogether, and yet they have had none the less the true 
choleraic disease. Others suffer more profuse and exhausting losses of 
water by the discharges, or their vital power of resisting disease is less, 
and they pass into more or less deep collapse; or hang, as we have seen 
them, on the ver}^ edge of that condition, for one or two days, and then 
emerge from the danger, without having done more than cause the ex- 
perienced physician the grave anxiety which such suspense must and 
ought to create. During these doubtful moments of the attack, the 
child should be kept as quiet and still as possible. He should be made 
to lie in a constantly horizontal position, on a smooth and easy mattress, 
in the crib, or on a large and roomy bed, and as little as may be on the 
lap, which is uneven and unsteady, and which must give his weak and 
exhausted muscles more work to do than they would have on the more 
solid and even bed. If, however, the nature of the child be such that 
he clings to the mother's or nurse's lap as his only safety, or if he have 
been taught (a most ill-judged lesson) to prefer the lap to any other 
position, we must j'ield to him, rather than cause fretting or unhappi- 
ness, when his very life may hang upon the avoidance of all disturbing 
influences. In this case, it is well to place him upon as firm a pillow 
as can be found, and let him be held on this in the lap. It is important 
to move him, when this becomes necessary, as slowly and gently as 
possible, always keeping the body on a horizontal plane, to avoid the 
tendency to the syncopal state, which sudden movements, and especially 
the sitting or erect position, are apt to produce. When the tendency 
to cooling of the body shows itself, and this is usually first noticeable 
in the hands and feet, ears and nose, he should be kept wrapped in 
warm, dry, and soft flannels or blankets. Flannels heated at the fire, 
thus supplying dry artificial heat, are of great use here. Bottles or tins 
filled with hot water, ought to be placed at the feet, under the blanket. 
A warm, soft, and light poultice of Indian meal or flaxseed, with a little 
mustard incorporated with it, may be placed over the abdomen, or three 
or four thicknesses of flannel, wrung out of hot water and whisky, may 
be laid over the lowest part of the thorax and over the abdomen, and 
covered with oiled silk, to retain their heat and prevent the wetting of 
the clothes. Whilst artificial heat is thus made use of, fresh air must 
not be excluded. On the contrary, as these cases almost alwa^^s occur 
in the hottest summer weather, the largest supply of fresh air that can 
be obtained must be admitted. Warm baths, which were proper and 



440 CHOLERA INFANTUM. 

useful during the early stage, especially when fever was present, we 
have not found useful in these cases. The fatigue and irritation caused 
by the disturbance of undressing and dressing the child, have seemed 
to us to do more harm than any good derived from the heat of the 
water compensated for. 

When the case takes a favorable turn, and the reaction stage begins, 
it is usually best to do nothing more than supply food and water care- 
full3^ and keep the body quiet and tranquil. The food may be cau- 
tiously and slowly increased in quantit}^ if the stomach has become 
settled. Tablespoonfuls of thin chicken tea, just flavored with salt, or 
of Liebig's cold extract of beef, or of light beef tea, or of a mixtui-e of 
wine-whey with two or three parts of thin arrowroot decoction (a tea- 
spoonful to a pint), may be given every half hour or hour. If these are 
retained several times, and the child shows some little anxiety for food, 
the same materials may be given in wineglassful quantities. At the 
same time, water and ice ought to be allowed from time to time, as the 
thirst may call for them. On the second or third day of the reaction, 
we may give, if the child shows a desire for it, a little milk and Avater 
and lime-water, one part of milk to one or two of water, with one of 
lime-water, commencing with not more than two or three ounces of the 
mixture at each feeding. The milk ought certainly to be very much 
diluted for the first three or four da^-s after it is allowed. When the 
child has been carried thus far safely, we may gradually return to its 
former habits of feeding, allowing meat to suck, a little bread, and so 
on, if it is old enough for such habits. 

As to drugs during the reaction stage, they are not necessary if 
everything goes on well. If, however, the fever run high, we may 
use small doses of the spirit of nitrous ether, as ten drops, in iced water, 
every two hours at one year, or twenty drops of the solution of acetate 
of ammonia, in the same manner, at the same age. If, as often hap- 
pens, the urinary secretion remains scanty, water, in such quantities 
as the stomach takes willingly, makes probably the best diuretic; or 
we may use the spirit of nitrous ether, as just recommended, with a 
grain of acetate of potash and half a drop to a drop of tincture of digi- 
talis, every two hours, for a day or two. 

When reaction is thus successfully brought about, the child may 
either improve rapidly and regain its previous health, or simple or in- 
flam?r»atory diarrhoea may set in, and pursue the usual course of those 
disorders. In the latter event, the child, if the attack of cholera have 
occurred in the city, ought certainly to be removed to the country if 
possible, since it is only too apt to have a recurrence of the choleraic 
disease if kept in town, or to suffer, at least, a tedious and more or less 
dangerous attack of the simpler form of diarrhoea. For the proper 
treatment of either of these sequences to cholera, the reader is referred 
to the articles on those diseases, with the warning, however, that all 
such patients ought to be treated with every minute care as to hygienic 
and therapeutic measures that experience and art have taught us, since 
the health has been so rudely shaken by the sickness already endured. 



TREATMENT. 441 

We have now laid before the reader, to the best of our ability, what 
we think is the best method of treating cholera in children ; but, before 
quitting the subject entirely, we T^ish to make a few^ remarks upon 
points not referred to in the above account. 

Attention to the state of the gums should never be neglected in teeth- 
ing children. Our experience leads iis to believe most implicitly that 
the process of dentition, or at least that and other concomitant consti- 
tutional conditions, are constant predisposing causes of gastro-intestinal 
disorders in early life, and that the active hjq^eraemic state, or positive 
acute inflammatory condition, which often attends upon the near ap- 
proach of teeth to the surface of the gum, may become an exciting 
cause of acute digestive diseases, such as cholera. We think it is al- 
ways well, therefore, to examine into the state of the mouth in a chol- 
eraic child as in other infantile disorders; and if the teeth are felt dis- 
tinctly through the gums, and the gums be found swollen, tense, hot, 
and highly vascular, to cut them freely once. If, on the contrary, the 
gums are firm, not hot, not redder than usual, and the edges of the 
teeth cannot be felt, it is foolish meddlesomeness to cut them. 

Baths. — In the earlj^ stage of cholera, before collapse has begun, and 
whilst the child is still reasonably strong, and particularly when there 
is marked febrile heat and dryness of the body, we think that the use 
of the warm or hot bath, or of sponging with hot water and spirit, are 
excellent measures. The bath maj^ be used twice, or even three times 
a day if the child does not resist and scream. The temperature should 
be 95^ to 98", and the child may be kept in the water from five to ten 
minutes. It is an excellent pjlan to wrap the child, directly on lifting 
it from the bath, in a heated muslin sheet, and to apply over this a 
blanket, and keep it thus enveloped on the lap for half an hour or 
more if it is comfortable and disposed to rest. If the child be some- 
what weak, whisky, added to the water, renders the bath more useful 
and safe. When the use of a bath alarms or annoys so as to cause 
violent agitation, it is best to substitute sponging with hot water and 
whisky or vinegar, under a light blanket, two or three times a day. 

Antiphlogisiics. — It may appear to many, in these modern times, a 
mere waste of words for us to state that we are opposed to bloodletting, 
in any form or at any stage of cholera infantum. But if any such will 
take the trouble to look over the works of wn-iters of ten and tw^enty 
years back, he will find reason to think that if this be our opinion, it 
ought to be expressed. When one of ourselves began to practise, in 
1841, it was quite the custom to take blood for the nervous symptoms 
w^hich are present in the early stage, and still more for the comatose 
phenomena at the close. This was done on the theory that these sj'mp- 
toms were theresult of congestion or inflammation of the brain, whereas 
now the}^ are looked upon as the results of exhaustion, of the altered 
conditions of the blood, or of uraemia. 

Calomel. — The opinion was expressed in a former edition of this work, 
that the doses of calomel usual 1}^ recommended w^ere too large for 
young children, and were ape to aggravate the existing irritation of 



442 DYSENTERY. 

the digestive mucous membrane; and that such doses of a remedy ac- 
knowledged to be a powerful sedative, could not be projDer in a disease 
which constantly tended towards exhaustion and collapse. It was also 
stated that the small doses which we did recommend had been declared 
by some critics to be entirely too small, and that to this we could only 
reply that the larger and more careful, and, we hoped, the wiser our 
observation had been in the last few years, the more thoroughly con- 
vinced were we that the larger doses, such as were former!}" recom- 
mended and used b}' nearly all writers and practitioners, were not only 
Tinneccssarily large, but most seriously objectionable. We went on to 
say that the indiscriminate use of this remedy, in nearly all cases of 
the gastro-intestinal diseases of childhood became with some, we be- 
lieved, a mere routine habit — that they never tried what might be 
accomplished without it, but went on pushing the drug in constant 
doses, when the case, if trusted to simpler means, or even left to the 
efforts of nature, would often do much better, we had learned to believe, 
than when these delicate organs were made the receptacle of doses 
that could not but tend to keep up the nausea, and vomiting, and diar- 
rhoea, which form so important a part of the morbid phenomena. The 
experience we have had since that time has but confirmed us in these 
opinions. Indeed we have so often been disappointed in obtaining any 
good effects from this drug, and have so often had reason to think that, 
instead of allaying nausea and vomiting, it increased them, and added 
to the exhaustion which is one of the dangers always to be contended 
against, that we have virtually abandoned it. 



AETICLE lY. 

DYSENTERY. 

Jt seems to us unnecessary to make more than a few remarks on 
dysentery, since we have already spoken of the morbid conditions of 
the large intestine, in our article on entero colitis. Dysentery", how- 
ever, differs from this latter affection by the fact that it frequently 
occurs in an epidemic form, and that there is a tendency to more rapid 
and extensive ulceration of the mucous membrane of the rectum and 
colon. It is an acute febrile disease, characterized by frequent evacua- 
tions, attended with more or less severe pain and straining, and con- 
sisting of muco-sanguinolent or sanguineous substances, which are due 
to ulcerative inflammation of the rectum and colon. 

The causes of dysentery are but little understood, beyond the mere 
facts that it occurs as an endemic in some regions of country, and as 
an epidemic over large districts. It is frequent, also, as a sporadic dis- 
ease, and in this form seems to depend upon the same causes as those 
already cited as productive of entero-colitis. Like cholera infantum, 



CAUSES — ANATOMICAL LESIONS — SYMPTOMS. 443 

it appears to be more common in bo3's than girls, since of 39 cases of 
which we have kept notes, in which the sex is mentioned, 27 occurred 
in boYS, and only 12 in girls. It is most frequent in the second and 
third years of life. Of 38 cases in which the age was noted, 1 occurred 
in the first year of life, 15 in the second, 7 in the third, 3 in the fourth, 
3 in the fifth, 1 in the sixth, 3 in the seventh, 3 in the eighth, and only 
2 from the eighth to the end of the eleventh year. It may be either 
idiopathic or secondary. As a secondary affection it is most apt to 
follow measles and variola. A7e have often known dj^senteric stools to 
occur in the course of cholera infantum, and in a considerable number 
of cases such as we have described under the title of enterocolitis. 

The anatomical lesions are confined chiefly to the large intestine, and 
are the same as those described under the head of entero-colitis, ex- 
cept that thc}^ are of a graver character. The mucous membrane is 
commonly found thickened, swelled, red, and softened; the submucous 
tissue sometimes presents ecch^niiosed points; the follicles are often 
diseased, their orifices being enlarged and ulcerated, as described under 
entero-colitis. In grave cases, particularly those occurring under an 
epidemic influence, there are usuall}" more or less extensive ulcera- 
tions, which may implicate only the mucous, or extend to the muscular 
or even the peritoneal coat. In such instances, pseudo-membranous exu- 
dations are often formed, sometimes in large quantity, and often cov- 
ering the ulcerations. The intestine contains sanguinolent mucus, or 
at times a brownish or greenish material, which is evidentlythe result 
of a gangrenous condition of the mucous membrane, pus, and lastly 
false membranes. In some rare cases, perforation has been known to 
take place. 

Symptoms. — The symptoms are much the same as those already de- 
scribed as existing in entero-colitis, excepting that the local symptoms 
are more severe, and the presence of blood in the stools constant. The 
disease often begins as a diarrhoea. The stools at first contain feculent 
materials, but after a time become very thin, small in quantity, and 
consist chiefly of mucus mixed with blood. The blood may be black 
and in considerable quantity, or of a dark rosy red color, or like the 
washings of flesh; it is mixed with greenish or yellowish substances, 
whitish mucus, fragments of false membrane, or purulent fluid. In 
young children there is evidently ^^m, from the restlessness, moving 
of the limbs, and crying about the time of the evacuations, while in 
those who are older, there is true tenesmus, like that observed in adults, 
and severe pain in the anus. The number of stools varies according 
to the severity of the case. There may be only four, eight, or ten in 
the day, or many more. We have quite frequently known as many as 
30 and 40 to be voided in the twenty-four hours, and in fatal cases, the 
dejections sometimes number three or four in an hour, while between 
the discharges the child often suffers from most violent and painful 
tenesmus. 

The abdomen \^ generally distended, tympanitic, warmer than natural, 
and painful. 



444 DYSENTERY. 

In mild cases there is iisuall}^ no fever, or very little, while in severe 
attacks, tliere is hi_o-h fever during the first few days, marked by fre- 
quent pulse, hot dry skin, followed after a time, unless a favorable 
change takes place, b}^ coolness of the surface, contraction of the coun- 
tenance, hollow, sunken expression of the eye, rapid emaciation, and 
death. 

It is useless to give a longer detail of the symptoms, as they are the 
same as those already described in the article on entero-colitis. 

The diagnosis presents no difficulties. The frequency of the dis- 
charges, the pain in the course of the colon and in the anus, the tenes- 
mus, the character of the evacuations, and the febrile reaction, all make 
the disease easy of recognition. 

11\\Q jprognosis is favorable in mild cases, unattended with much fever, 
or very frequent discharges. When, on the contrary, there is violent 
fever in the beginning, followed by disposition to coolness and collapse; 
when the stools are exceedingly frequent, and attended with severe 
pain and almost constant straining; and when they consist of nothing 
but mucus, mixed with considerable quantities of blood, or with pus or 
false membranes, the prognosis is very unfavorable. Of 36 cases, the 
termination of which we have recorded, 4 proved fatal. 

Treatment. — The treatment of dj^sentery in children is often very 
unsatisfactory. The mere varietj^ of the remedies recommended by 
different writers and practitioners marks the uncertainty of the effects 
obtained from drugs. Mild cases so generally get well under any treat- 
ment that all methods have had their supporters and advocates, while 
grave cases, and especially those occurring under the influence of severe 
epidemic visitations, are so difficult of treatment, and often so little 
under the evident control of medical means, as to leave the careful ob- 
server in great doubt as to what he ought to set down as the evident 
result of his own interference in the case, and what as the results of the 
efforts of nature to cure the disease. 

Mild cases of the disease, in which the fever is not very high, the 
number of stools not great, and the pain and distress moderate, require 
little else than rest in bed, a light and unin-itating diet, and the use of 
opium in small quantities either internally or by injection. When there 
is reason to suspect the presence of unwholesome food in the stomach, 
or of unhealthy secretions in the intestines, it is necessary to give in 
the beginning small doses of some mild carthartic. The one generally 
preferred is castor oil, which may be given either simple, in the dose of 
a small teaspoonful containing one to four drops of laudanum according 
to the age, or in the form of emulsion. The latter is the mode of em- 
ploying it usually chosen. A drachm of oil should be rubbed up with 
a scruple of gum, a little sugar, from two to eight drops of laudanum 
according to the age of the child, and seven drachms of some aromatic 
water. The dose is a teaspoonful every three or four hours. If the 
case continue to improve under the emulsion, it may be continued for a 
couple of days, but should the stools become more and more frequent, 
and the pain and tenesmus increase, it must be suspended after one or 



TREATMENT. 445 

two days, and laudanum enemata, with or without the internal use of 
absorbents and astringents, substituted. The injections ought to con- 
sist of four or five drops of laudanum at two years of age, and of ten 
drops at five or six 3' ears, suspended in from half an ounce to an ounce of 
some mucilage, or thin farinaceous fluid, or simply mixed in a tablespoon- 
ful of tepid water, whicii is perhaps the best plan of all. The injections 
may be given eveyy four or six hours if necessary, or they may be 
made use of only at night, while small doses of Dover's powder are ad- 
ministered every three or four hours through the day. 

The diet in these cases should consist of arrowroot, sago, tapioca, or 
some such food, made into thin pap with milk and water; and the quan- 
tity allowed ought to be very moderate. Eest in bed, in the cradle, or 
in the lap, is very important. The child ought not to be allowed to run 
about, or use exertion of awj kind. 

Where the pain is severe and the fever high, and where there is a 
good deal of soreness in the abdomen, depletion may with propriety be 
resorted to, but always with moderation and prudence. A few leeches 
applied around the margin of the anus, or to the surface of the abdo- 
men, often prove of great service in relieving pain and tenesmus. An 
occasional warm bath is very soothing and useful. 

In ver}^ severe cases of dysentery the treatment is, as above stated, 
difficult and uncertain, owing to the dangerous character of the disease, 
and to the fact that so many diff'erent methods have been recommended 
by different writers. 

In the early stage of a severe case, whilst the febrile reaction is high 
and the strength of the patient still unsubdued, depletion by leeches in 
young children and by venesection in older ones, is strongly approved 
of by many able practitioners. For our own part we have not resorted 
to it as a general rule, from the fact that we have so often found the 
strength of the child to fail rapidly under the disease itself. In a few of 
our cases, however, leeching around the anus has been followed by mani- 
fest benefit. The remedies most commonly depended upon are castor 
oil in emulsion with laudanum, mercury, sugar of lead, opium, nitrate 
of silver, spirit of turpentine, and astringents. The castor oil emulsion, 
prepared as mentioned above, is useful in the early part of the attack, 
but ceases to be so, according to our experience, after the first twenty- 
four or forty-eight hours. From mercury we have not ourselves ob- 
tained any very positive benefit, though, in combination with opium 
and ipecacuanha in small doses, it is much thought of by many excel- 
lent authorities. The only remedy which is used by all, though it is 
rarely given alone, is opium, and the very fact that it is so universally 
employed points it out as one of the most reliable and valuable means 
we have at our command. It is certainly the one upon w4iich we most 
depend ourselves. It may be given either alone or in connection with 
other substances. Where injections can be retained it is best given in 
that wa}". About five drops of laudanum at two 3'ears of age, or ten 
drops at four or five years, may be given in a tablespoonful of any bland 
vehicle every four hours. When the rectum rejects the enema as soon 



446 DYSENTERY. 

as administered, the opium should be given either by the mouth, in the 
form ofhiudanum or solution of morphia, or in that of Dover's powder; 
or in the form of suppository. We should indeed strongly recommend 
the administration of opium in this latter form in such cases, since we 
unquestionablj' obtain a certain beneficial local action, in addition to its 
constitutional effect through its absorjDtion. The amount of opium 
should be about the one-eighth of a grain at two years of age, which 
should be incorporated with butter of cocoa, a most bland and soothing 
substance, which dissolves readily at the temperature of the body. When 
made of this substance, and of proper shape and sufficiently small, the 
suppository can be introduced without pain, and will usually be re- 
tained. They should of course be repeated at intervals, depending 
upon the effect produced. Opium is almost always emploj-ed in con- 
nection with some other remedy, and particularly with calomel or ace- 
tate of lead. The dose of calomel is from a sixth to half a grain, or, as 
used b}^ some practitioners, a grain, with a twelfth of a grain of opium, 
or half a grain or a grain of Dover's powder, dvery three or four hours, 
for children two or three years of age. The acetate of lead is more 
relied upon, and has probably higher testimony in its favor than calo- 
mel. We have ourselves obtained excellent effects from it in some in- 
stances. The dose is from half a grain to a grain every two or three 
hours at two and three years of age. 

There are two other remedies not yet mentioned, which have been 
of more positive efficacy in our own practice than any others, with the 
exception of opium. These are the nitrate of silver and the solution 
of the nitrate of iron. The former we have used both internally and 
by injection, the latter only by injection. For an account of the mode 
in which these remedies are employed by different authorities, the 
reader is referred to the remarks on chronic entero-colitis. We have 
employed nitrate of silver in 14 cases of dysentery. These were all 
severe attacks, and some of them most violent. Of the 14 cases, three 
died. The remedy was given by the mouth alone in 7 cases, by injec- 
tion alone in 5, and by the mouth and by injection both in 2. It has 
proved most beneficial in its effects, in our hands, when given by the 
mouth, though its influence over the disease has always been less im- 
mediate than when used by injection, but it has been more permanent. 
The dose in w^aich we have used it has varied with the age of the child, 
and with the severity of the symptoms. For children two years old 
we have usually employed from one grain to one and a half grains, and 
for those of five or six years or upwards, two grains dissolved in two 
ounces of a vehicle, consisting of an ounce each of syrup of gum arabic 
and distilled water. The dose is a teaspoonful every two or three 
hours. It is well, as a general rule, to add from four to sixteen drops 
of laudanum, according to the age of the subject, to the mixture. For 
use by injection we have commonly employed for each enema two grains 
for young children, and four grains for older ones, dissolved in four 
ounces of distilled water. The injections are to be repeated twice or 
three times a day. After the nitrate of silver enema has come away, 



DISEASES OF THE C(ECUM AND APPENDIX C(ECI. 447 

it is a good plan to throw into the bowel a laadanum and starch injec- 
tion. 

We have made use of the solution of nitrate of iron, to which allu- 
sion was made above, only as an injection in acute dj^sentery. We 
have employed it in eight cases, and are quite sure that it was of essen- 
tial service in six, while in two it appeared to irritate, probably because 
the quantity given was too large. Our mode of applying it is to mix 
from ten to twelve drops in four ounces of tepid water for each injec- 
tion. The injections were given twice or three times a daj^, and they 
were followed, as soon as tliey had returned, by a laudanum injection. 
On two occasions, the nitrate of iron injection remained in the bowel 
for several houi-s before being rejected, and thus restrained for that time 
the stools, which had previously been very frequent, and attended with 
much tenesmus. 

When the stools continue very frequent in spite of the use of opium 
in some of its many shapes, when sugar of lead and nitrate of silver 
have been employed without controlling the frequency of the discharges, 
vre have sometimes found the mixture of aromatic sulphuric acid, laud- 
anum, and syrup of rhatany, before recommended, very beneficial. 
When the stools, in addition to their dysenteric characters, have been 
water}', and greenish in color, the chalk mixture, with laudanum and 
tincture of rhatanj^, kino, or catechu, repeated eveiy two hours, with 
occasional laudanum enemata, has been very useful. 

The hygienic management of dysentery should be precisely the same 
as that which was suggested as pro2)er for entero-colitis. 



ARTICLE y. 

DISEASES OF THE CCECUM AND APPENDIX CCECI — TYPHLITIS AND 
PERITYPHLITIS. 

Synonyms; Definition.— The diseases of the coecum and of its ver- 
miform appendix are so important and frequent, and present so many 
peculiarities, as to demand a separate and detailed consideration. In 
approaching their discussion, it is necessary to bear in mind several 
important points in which the coecum differs from the rest of the large 
intestine. Thus its ])eritoneal investment is deficient over the posterior 
part, which is generall}' quite firmly attached to the right iliac fossa by 
connective ti.^sue, containing a small proportion of fat. Its anatomical 
relations moreover indicate that the semi-feculent materials passing from 
the ileum are destined to be retained in the coecum to undergo some 
important action. The ileum at its ower portion rarelj' has a calibre 
greater than one-third that of the coecum, a circumstance which must 
materially retard the progress of the contents of the latter, and a further 



448 DISEASES OF THE CCECUM AND APPENDIX CCECI. 

detention is caused by the ileo-coecal valve, which prevents all reflux, 
and by the position of the caecum, which compels it to force onwards its 
contents in opposition to gravity. The view that the coecum is the 
seat of an important part of the digestive process, either in the appro- 
priation of any remaining nutritious elements of the semi-feculent 
chyme, the absorption of its water}' parts, or the elimination of some 
excrementitious matter from the system, receives confirmation from 
the very rich vascular and glandular supply of the walls of this part of 
the intestine. 

In addition to this, the coecum has opening into it, usually at its lower 
and back part, the appendix vermiformis, a narrow, elongated, gland- 
ular process, varying from three to six inches in length, and having an 
average diameter about equal to that of a goose-quill, although its 
calibre is quite small. It is usually directed upwards and inwards be- 
hind the coecum, and lies coiled upon itself. Its function aj^pears to be 
the secretion of a viscid ropy mucus. 

We thus see in the anatomical and physiological relations of the 
coecum strong predisposing causes of many morbid conditions. Among 
these the most frequent are distension and impaction of its calibre by 
hardened fseces; the lodgment of a foreign body or intestinal concre- 
tion in one of its pouches or in the appendix, an accident wliich often 
excites violent and destructive inflammatory action ; and finally local- 
ized inflammation of one or all of the coats of the coecum or the ver- 
miform appendix. 

This last condition has received the names of typhlo-enteritis, from 
ruc/jjc, blind, and evre/>ov, intestine; typhlitisj and ccecitis, from the 
Latin word coscum, also signifying blind. 

The pericoecal connective tissue is also occasionally the seat of in- 
flammatory action, constituting a condition known as perityphlitis. 

Seat and Character. — Clinical experience and the researches of 
pathological anatomy fully justify us in recognizing the above-men- 
tioned morbid conditions, but the question as to their relative frequency 
and importance is still far from being settled. 

By some authorities the diseases of the coecum are regarded as sec-. 
ondary to morbid affections of the appendix, the latter consisting gen- 
erally in the presence of foreign bodies, or of hardened, inspissated 
mucus, which act as the focus and exciting cause of the inflammation 
of the coecum. 

It is probable, however, in regard to the simple form of typhlitis, 
that both the coecum and its appendix are subject to a peculiar localized 
inflammation, involving all their coats, and due to the temporary arrest 
of some foreign substance or intestinal concretion in their cavitj', or to 
the action of the causes to be hereafter considered. It is indeed pos- 
sible that the inflammation excited by the presence of a foreign body 
maj^ subside^ whilst the cause still remains arrested in the appendix or 
one of the pouches of the coecum; but experience would lead us to 
infer, that, when once inflammatory action has been excited, so long as 
the foreign substance which has caused it remains in contact with the 



CAUSES. 449 

mucous membrane, the tendency is usually to produce ulceration and 
perforation of the coats of the bowel. 

We find this same discrepancy of opinion in regard to those cases 
attended with perforation of some portion of the ccecum, and the forma- 
tion of an abscess in the iliac region. Dupuytren, who was the first 
to call attention to the pathology of these iliac abscesses, attributed 
them to suppurative inflammation of the pericoecal connective tissue, 
produced in many cases by extension of inflammation from the coats 
of the ccecum, and held that the perforation of the bowel often found 
in connection, was a secondary phenomenon, and was in fact the mode 
by which the abscess was discharged. Inflammation and suppuration 
of the pericoecal tissue does indeed occur as an idiopathic a ection, or 
from extension of inflammation from the ccecum, but it is of extremely 
rare occurrence; and there can be no doubt that nearly all cases of 
iliac abscess are due to perforative ulceration of either the ccecum or 
appendix. As Bouchut suggests, one proof that most cases of non- 
puerperal iliac abscess are thus due to perforation of the ccecum or 
appendix, is aff'orded by their almost constant occurrence upon the 
right side. Thus of 57 non-puerperal iliac abscesses collected by G-ris- 
solle, 9 only were on the left side; while of 26 puerperal ones, 15 were 
on that side. 

It is necessary, however, to carry this question one step further, and 
to determine, if possible, the relative frequency of perforation of the 
ccecum and of the appendix. It has been supposed, as by Ferrall, that 
ulceration of the ccecum is in most cases the starting-point in the de- 
velopment of the lesions. But, while we are in possession of a suflfi- 
cieut number of recorded cases, 12 of which we have collected, where 
post-mortem examination has proved the abscess to have originated in 
perforation of the ccecum, there is good reason to believe that perfora- 
tion of the intestine is much more frequently found associated with 
disease of the appendix than with ulceration of the ccecum itself. 

Causes. — In addition to the anatomical peculiarities of the coecum 
and appendix, which must be regarded as predisposing causes of these 
afl'ections, there are other conditions which exert an unquestionable 
influence. 

The strumous diathesis has been regarded as a predisposing cause of 
diseases of the coecum and appendix. It does not appear, however, 
that inflammation of these parts is more frequent in strumous subjects, 
but merely that it has a greater tendency in such patients to run on to 
ulceration and perforation of the bowel. 

Age. — The greater irritability and proneness to inflammation which 
the intestinal canal presents in early life, appears to have its eff'ect 
upon the development of typhlitis, since a considerable majority of 
reported cases have occurred under the age of 25 years. This is par- 
ticularly true of the milder attacks, which are not attended with ulcer- 
ation. Thus, of 38 cases of tj^phlitis at all ages, which recovered with- 
out perforation of the bowel, 29 occurred at or under the age of 25 ; 9 
only were in older persons. Of these 38, 13 occurred in our own prac- 

29 



450 DISEASES OF THE CCECUM AND APPENDIX C(ECI. 

tice, and were aged as follows: 2 under six years; 6 between 6 and 12 
years ; 5 between 12 and 15 years. Finally, 19 of the 38 cases occurred 
at or under the age of 15 years. This does not appear to hold true, 
however, with regard to perforative ulceration of the coecum and ap- 
pendix. 

We have not met with any case of perforation of the coecum occur- 
ring during childhood, but of 25 cases collected from different sources, 
13 occurred after the age of 25 : 12 at or under that age. Of these 25 
cases, 12 only were verified by post-mortem examination, of which 3 
were under 15 years of age, 2 between 15 and 25 j^ears, and 5 above 25 
years. 

Of perforation of the appendix vermiformis, we have met with 3 
cases in children, aged respectively 4J, 8, and 11 years. Of 25 other 
cases, collected from various sources, in which the age is stated, 9 were 
above, 16 below 30 years of age. Of these 16, 3 only were under 15 
years of age, so that, including our own 3 cases, we find 6 cases occur- 
ring under 15 years, 13 between 15 and 30, and 9 above 30 years of age. 

Sex. — The influence of sex has been very, variously stated by dif- 
ferent observers. It appears, however, that males are somewhat more 
prone to all these forms of disease than females. Thus of 39 cases of 
typhlitis, which recovered without perforation of the bowel, 23 were 
in males; 16 only in females. Of 13 of these 39 cases, which we ob- 
served in children, 8 were males and 5 females. 

Of 25 cases of perforation of the coecum, 13 occurred in males; 12 in 
females. 

The sex is stated in 27 of 32 cases of perforation of the appendix. Of 
these, 21 were males; 6 or\\j were females. Of 6 cases occurring under 
15 years of age, the sex is stated in 5, 4 of which were males. 

Occwpation. — Various occupations, especially those involving seden- 
tarj- habits, have been supposed to predispose to these affections, as 
also the practice among females of wearing tight corsets. Experience, 
however, has not verified these suppositions. 

Constipation. — A constipated state of the bowels undoubtedly pre- 
disposes to these affections by favoring the production of a distended 
and impacted condition of the coecum, even if the presence of the 
hardened fecal matter does not prove the exciting cause of some cases 
of typhlitis. Eokitansky considers this cause so important that he has 
given the name typhlitis stercoralis to one form of inflammation of the 
coecum. 

Exciting Causes. — Cold and Exposure.- — The action of these ordi- 
nary exciting causes has been denied by some observers on account of 
the frequent absence of a chill or rigor at the inception of the attack, 
and the development of the local before the general symptoms. It 
cannot, however, be doubted that typhlitis maj^ be idiopathic and arise 
from the ordinary exciting causes, though the cases are comparatively 
rare. 

Food. — In several instances the attack appears to have been brought 
on by the use of indigestible or irritating articles of diet, among which 



CAUSES. 451 

may be especially mentioned unripe acescent fruits. It has been said 
that the use of oatmeal, which favors the formation of intestinal con- 
cretions, is also liable to be followed by this disease. It does not. how- 
ever, appear that typhlitis is any less frequent in countries where 
wheaten bread is used, than in those w^iere oatmeal forms a chief part 
of the food. 

Blous or Exertion. — There are a few cases recorded in which a blow 
upon the abdomen, or a sudden violent strain, appears to have been the 
immediate cause of an attack of typhlitis. 

Foreign Bodies and Intestinal Concretions. — This class, comprising very 
various substances, certainly forms the most important and frequent 
cause of diseases of the coecura and appendix. 

We cannot be positive as to the amount of influence they exert in 
the milder and more tractable cases of simple typhlitis, though it is 
quite probable that many of these are caused by the temporary arrest 
of some foreign substance in the appendix, or one of the pouches of 
the coecura. Thus, in a case reported by Dr. Wynn Williams (^Lancet, 
January 25th, 1862). in a male adult, three months after a well-marked 
acute attack of typhlitis, which yielded to judicious treatment, a large 
intestinal concretion, having a plum-stone for a nucleus, w^as passed by 
the rectum. They are, however, the efficient cause of a large majority 
of all the cases of perforative ulceration of the coecum and its appendix. 

The diseases of this latter part, however, are far more uniformly de- 
pendent upon the presence of foreign bodies even than in case of the 
coecum; almost three-fourths of all recorded cases of perforation of the 
appendix having been due to this cause. In 6 cases occurring in chil- 
dren, some extraneous substance was found in the appendix in each 
one; in 2 a foreign body was present; and in each of the other 4, an in- 
testinal concretion. 

Many of these bodies are true intestinal concretions, having for their 
nucleus merely a nodule of hardened faeces or inspissated mucus. They 
vary considerably in size, the majority of them being about the size of 
a cherr^^-stone or date-stone, though Habershon mentions having seen 
one as large as a hen's-egg. They are also of very varying consistence, 
according to Yolz, as quoted by Hanbury Smith, constituting three 
varieties: the soft, resembling excrement in appearance and odor, and 
having a nucleus of hardened fecal matter; the semi-hard, of a grayish- 
brown color, consisting of shining concrete layers, with a nucleus which 
is not a foreign body; and the stony, which are of a grayish-white or 
earthy color, and have a surface from which may be detached delicate 
scales, or which is smooth, shining, yellowish-white, or brown and 
studded with calcareous projections. 

Many of these concretions consist of carbonate and phosphate of lime 
united with inspissated mucus. Copland also mentions one which con- 
sisted of cholesterin. 

In addition to these, however, numerous foreign bodies have been 
found in connection with the coecum or appendix, either free or form- 
ing the nucleus of an intestinal concretion. Among these may be men- 



452 DISEASES OF THE CCECUM AND APPENDIX CCECI. 

tioned grape-seeds, cherry-stones^ date-stones, pins, bristles, fragments 
of glass, biliary calculi, and balls of worms, either ascarides or lumbri- 
coids. 

It may not be amiss to remark, here, that some intestinal concre- 
tions resemble, to a marked degree, the seeds or stones of different 
fruits, particularlj^of the cherr}^ date, and plum; and there is no doubt 
that man}^ of the bodies found in the coecum or the appendix, and 
reported as cherry-stones or date-stones, have been in reality intestinal 
concretions. 

Whatever be the nature and origin of these bodies, it is probable that 
in many cases some morbid condition of the mucous membrane of the 
coecum or appendix precedes their formation or lodgment, and the de- 
velopment of the grave symptoms which often follow. 

As Habershon justly remarks, the ordinary calibre of the appendix 
is so extremely small and so thoroughly lubricated, that it must be 
very rare for any extraneous substance to become impacted in it so 
long as it remains healthy. A further argument in favor of this view 
is the fact that the presence of these concretions is attended by the 
most varjang results, since very large and irritating bodies have been 
occasionally found occupying the cavity of the appendix without 
having produced any sj^mptoms during life, or any inflammation of its 
surface; while, on the other hand, minute concretions of semi-solid 
consistence, and apparently unirritating in character, have frequently 
been observed to act as the foci of the most serious and destructive in- 
flammatory action. 

Anatomical Appearances. — In the simple forms of typhlitis, the 
mucous membrane of the coecum presents the usual appearances of in- 
flammation ; the peritoneal investment is also involved, and besides 
injection and opacity of this membrane, there are adhesions formed be- 
tween folds of the intestines. 

When, however, ulceration is present, as often results from the pres- 
ence of foreign bodies, or in strumous subjects, it is a matter of the 
utmost importance which portion of the coecum is involved, since, as 
such ulcers have a strong tendency to perforate the coats of the bowel, 
if they occur on the anterior part of the coecum, which has a peritoneal 
investment, there is the greatest danger of an escape of the contents of 
the bowel into the peritoneal sac, and the development of rapidly fatal 
peritonitis. Thus, of 10 fatal cases of perforation of the coecum, in 
which the seat of the perforation was determined by post-mortem ex- 
amination, the anterior wall was involved in 6 instances. If, on the 
other hand, the ulcer be seated on the posterior part of the coecum, 
where it is attached to the iliac fossa b}^ connective tissue, and devoid 
of a peritoneal covering, perforation is not directly followed by any such 
unfortunate results. Inflammation is excited in the pericoecal connec- 
tive tissue, suppuration ensues, and the resulting abscess follows one of 
several courses, precisely as in idiopathic suppuration of the pericoecal 
tissue. Thus it may reopen into the bowel; may burrow along the 
sheath of the psoas muscle, and point below Poupart's ligament; or it 



ANATOMICAL APPEAKANCES. 453 

may discharge in the lumbar region, or at any point along the crest of 
the ilium. 

In one case the iliac artery ^vas opened, leading to speedy death from 
hemorrhage. 

Occasionally these abscesses discharge themselves by more than one 
avenue, as for instance through the bowel, and in the groin or iliac 
region simultaneously. When, as occasionally happens, the inflamma- 
tion of the coecum passes into a chronic form and the ulcerative process 
ceases, the adhesions of the coecum to the iliac fossa become preternatu- 
rally dense, the coecum itself is contracted, its coats thickened, and the 
mucous membrane almost entirely destroj^ed, or converted into a reti- 
form and trabecular fibroid tissue. Eokitansky has found in such cases 
the coecum converted into a slate-colored capsule, with dense parietes, 
of the size of a walnut or a pigeon's egg. 

The cqipendix venniformis may be the seat of catarrhal inflammation, 
associated with inflammation of its peritoneal covering. Death does 
not result from this condition, but the pathological appearances are 
probably analogous to those found in all cases of localized sero-enteritis. 

When, however, the appendix has been the seat of ulceration, and 
death has resulted before perforation has occurred, its cavity is found 
distended with pus, its mucous membrane deeply ulcerated, and in 
nearly every instance, a foreign body or an intestinal concretion is 
present. 

The ulceration of the appendix varies in its position and extent, at 
times being seated at the free extremity, at others occupying the lower 
third of the appendix, which is perhaps the more frequent seat. In 
regard to its size, the ulcer and the subsequent" perforation may be 
either very small, or else may involve almost the entire circumference 
of the appendix. 

Under favorable circumstances, especially if the foreign body is dis- 
charged, the ulceration ceases, and the appendix becomes converted 
into a ligamentous cord, its calibre being entirely obliterated. 

When perforation of the appendix occurs, the results vary according 
to the degree of local peritonitis which has been excited. If the ap- 
pendix has become strongly adherent at the point where perforation is 
about to take place, this accident may not be followed by the develop- 
ment of general peritonitis. The points to w^iich the appendix gener- 
ally becomes adherent, are the coecum, the anterior abdominal wall, 
and the right iliac fossa. In the first case, the circumscribed abscess 
which follows the perforation of the appendix will discharge itself 
through the coecum b}^ effecting a perforation of its wall from without 
inwards, and this is the most favorable termination possible. When, 
however, the appendix has become adherent to the abdominal wall or 
iliac fossa, the resulting abscess will follow the course, already de- 
scribed, of abscess from perforation of the coecum. 

It is in this connection that the various abnormal positions which 
the appendix may assume, are of importance, as determining the posi- 
tion in which the abscess will j^oint. 



454 DISEASES OF THE CGECUM AND APPENDIX CCECI. 

Unfortunately, however, the adhesions are rarely strong enough to 
circumscribe the purulent matters escaping from the appendix, so that 
these generally find their way into the peritoneal cavity, and excite 
general peritonitis. 

We subjoin the histories of 3 fatal cases of perforation of the appen- 
dix from intestinal concretions, occurring in children, in all of which 
some local peritonitis with adhesions had occurred, but had not sufficed 
to prevent the above unfortunate termination. 

Case 1. Intestinal co7icretion in the appendix coeci, causing pei^foration and fatal pern- 
to7iitis. — T. D. S., a healthy, well-grown boy, 11 years of age, rose on the morning 
of December 25th, 1860, apparently quite well. Soon afterwards, however, he com- 
plained of pain in the right iliac and lumbar regions, was chilly, and returned to bed. 
A dose of castor oil was given him. In the course of the day fever came on. 

Next day he was feverish, with a pulse of 132, a hot and dry skin, and a moder- 
ately furred tongue. The pain still continued, with tenderness and slight distension 
of the abdomen on the right side; there was no vomiting. His bowels had been 
acted upon three times by the oil. Leeches and a poultice locally, and a mixture of 
blue pill with rhubarb syrup internally, were ordered. 

On the 27th and 28th, the symptoms were much the same, except that the tender- 
ness and distension increased. The pain was aggravated by coughing, by a full in- 
spiration, and by motion, especiall}'- of the right leg. The bowels were slightly 
moved by the mixture ; no vomiting as yet. His fever continued, but the pulse fell 
to 108, and his skin was somewhat cooler. 

On the 29th he was worse. All his symptoms were aggravated, and vomiting set 
in; his bowels became confined. Small doses of calomel and opium were given, en- 
emata of various kinds were tried, and rhubarb syrup with a little fluid extract of 
rhubarb was perseveringly employed, but without effect. The abdomen now became 
greatly distended, exceedingly sonorous, and painful; the stouiach grew more and 
more irritable, rejecting from time to time, towards the last, with a sudden spasmodic 
effort, everything that was taken by the mouth. The bowels were completely ob- 
structed, so that repeated injections of various kinds elicited no discharges., even of 
flatus. The urine continued to be secreted to the last ; and there was at times, in 
spite of the nausea and vomiting, quite a strong desire for milk and bread. 

During the last few days wine-whey and beef tea were given in small quantities ; 
and opium by enema and by the mouth was used to allay pain. On the third day of 
the treatment a blister four inches square was applied over the seat of tenderness ; 
but neither this nor any of the other remedies employed seemed to exert the least 
effect upon the course of the disease. 

Death took place on the eighth day, January 1st, 1861. 

The autopsy was made by Dr. Packard, twenty-four hours after death. Body 
large, muscular, and well formed ; rigor mortis well pronounced. Abdomen only 
examined. 

On making the usual section, several coils of small intestine, very greatly distended 
with gas, and markedly injected, with flakes of lymph here and there over the sur- 
face, at some points gluing the adjacent coils together, were seen concealing the rest 
of the abdominal viscera. After some search, the colon was found, very much con- 
tracted, except at the coecum. The ileum was in like manner contracted, the narrow- 
ing beginning at about the end of the jejunum, which formed the distended coils 
above mentioned. No cause was assignable for the constriction at this point; but a 
little lymph was thrown out here, and it may have been that the bowel had been 
twisted. 

The appendix vermiformis was bound down by periton-al adhesions. Within it, 
near its origin, was a mass as large as a small bean, but perfectly oval. Just beyond 
this mass, at what seemed to have been its position, was an ulcer extending all round 



CASES OF PERFORATION OF THE APPENDIX. 455 

the tube, and of a gangrenous aspect. At the distal end of this ulcer was a perfora- 
tion, by which matter had found an exit into the peritoneal cavity. The rest of the 
tube looked as if it had been distended by the pus before the opening was formed. 
After its escape from the appendix, the matter seemed to have caused a circumscribed 
peritonitis, in addition to the general one already indicated. The adhesions bound- 
ing this peritonitis had extended up to the liver, the convex surface of which was 
hollowed to a slight depth in an oval shape, the depression being lined by false mem- 
brane. The whole quantity of the pus was perhaps f5iv. 

The liver was pale in patches, but was not degenerated. Kather too large a num- 
ber of oil-drops existed in a dark, inflamed portion of its substance, just beneath the 
depression above mentioned ; but even here the quantity was not great. The mesen- 
teric glands were swollen and injected over the surface. No other lesions were 
observed. 

Case 2. Intestinal co?icreiio7i in the appendix coeci, cmising perforation and fatal peri- 
tonitis. — C. B., get. 4g years, was taken sick with slight fever, pain in the abdomen, 
some vomiting, constipation, and inflation of the abdomen. With these symptoms 
there was marked tenderness in the right iliac fossa. After three days the bowels 
were well opened, and the fever subsided ; the abdomen, however, continued inflated, 
and a small but distinct tumor had appeared just inside of the right anterior superior 
spinous process of the ilium. 

He continued to improve, and was apparently much better, but was 'strictly con- 
fined to bed, when on the ninth day at 3|- p.m., he was seized with severe abdominal 
pain ; symptoms of collapse rapidly appeared, and he died at 2 a.m., the following 
morning. 

At the autopsy an intestinal concretion of the shape and size of a date-stone was 
found in the appendix. The end of the appendix was perforated, and had become 
attached to the anterior wall of the abdomen, where a small abscess had formed in 
the cellular tissue between the peritoneum and the abdominal muscles, evidently 
seeking an outlet through the abdominal parietes. The wall of this had unfortu- 
nately ruptured into the peritoneal sac, and death had resulted in a few hours from 
general peritonitis. 

Case 3. R. P., a healthy girl, aged 7r} years, died at the end of the second week 
of a well-marked attack of perforative disease of the appendix vermiformis. 

At the autopsy a large, rounded intestinal concretion was found in the appendix 
coeci, which was perforated, allowing an escape of matter into the peritoneal cavity. 
There was marked general peritonitis, with the formation of a large quantity of pus. 

Symptoms. — Mere distension of the coeciim by hardened faeces, without 
actual inflammation of its coats, may be attended with constipation, 
some vomiting, and the presence of a somewhat sensitive tumor in the 
coecal region. According to Copland, when the distension by accumu- 
lated matters is great, it may, from rising high in the abdomen and 
pressing upon the nerves, vessels, and ducts in its vicinity, occasion 
numbness and oedema of the right lower extremity, retraction of the 
right testicle, and derangement of the urinary secretion, so as to be 
mistaken for disease of the kidney. 

Inflammation of the mucous membrane only of the coecum, is generally 
attended with a moderate degree of fever, slight pain and tenderness 
in the right iliac fossa, and some diarrhoea, with mucous, offensive 
stools. This condition is not unfrequently chronic, and evinces its pres- 
ence by no very positive symptoms, unless adjacent parts have become 
involved in the inflammation, or an acute attack of typhlitis supervenes. 

Typhlitis, or inflammation of all the coats of the coecum or appen- 



456 DISEASES OF THE COECUM AND APPENDIX CCECI. 

dix, usually appears suddenly during full health, or it may be pre- 
ceded by slight intestinal derangement, such as diarrhoea or consti- 
pation. 

Pain. — The earliest and most marked symptom is generally pain in 
the region of the coecnm, which appears suddenly, becomes fixed and 
constant, rarely remitting, and is greatly increased by a deep inspira- 
tion or by coughing. 

This pain is attended from the very first with such exquisite tender- 
ness on pressure in the right iliac region, that the weight of the bed- 
clothes cannot be borne, and the patient shrinks from the lightest touch. 
To relieve this pain the patient lies toward the right side, with the 
thighs flexed upon the pelvis, and any attempt to draw the right leg 
down causes agonizing suffering. These local symptoms are usually 
confined to the right ih'ac fossa, though the entire peritoneum may be- 
come somewhat involved, and the symptoms of general peritonitis de- 
velop themselves. 

Fulness or Tumor. — Owing to the distended state of the bowel itself, 
and to the 'adhesions formed between folds of the intestines, or in some 
rare cases to an inflammatory effusion behind the ccecum in the iliac 
fossa, there is marked fulness or even a well-defined tumor in the right 
iliac region. Frequently there will be merely fulness during the first 
few days of an attack, and then a distinct tumor will be developed. 
In 11 of 39 cases of acute typhlitis, recovering without perforation of 
the bowel, a distinct tumor was present. In most of the other cases 
the conditions of the coecal region is described as one of fulness or dis- 
tension. Of these 39 cases, 19 occurred in children under 15 years of 
age, in only 3 of which a distinct tumor is recorded to have been ob- 
served. 

Constipation. — The bowels are almost invariably constipated ; in many 
cases very obstinately so. This constipation is frequently associated 
wnth quite severe tormina and tenesmus, and if the coecum be much 
distended, there may be pain shooting down the right thigh, or numb- 
ness and even oedema of this part, together with retraction of the right 
testicle. 

It is important to observe here, that in most cases, when once the 
constipation is relieved, and free feculent stools procured, the most 
threatening sj'mptoms of the attack rapidly subside. 

Vomiting nearly always attends in children ; it was present in all of 
our 13 cases. It is never stercoraceous, and indeed is rarely trouble- 
some unless the constipation is marked, or perturbating treatment has 
been adopted in the beginning of the attack. 

Fever. — The attack is not usually ushered in by any chill or rigor; 
but marked febrile symptoms soon appear, the pulse becomes acceler- 
ated, the skin hot, the tongue furred, and the thirst extreme. These 
symptoms usuall}^ subside under appropriate treatment after a variable 
time, generally from four to twelve days ; the bowels are opened freely, 
the pain and tenderness diminish, and the fulness in the right iliac 
region gradually disappears. 



PERFORATIVE ULCERATION OF THE APPENDIX. 457 

This description of symptoms applies to acute inflammation both of 
the ccecum and appendix, as there are no well-recognized differences 
in the symptoms of these two conditions. The only probable points of 
difference are, that in inflammation of the appendix the pain is more 
acute, and the thorough evacuation of the bowels is not followed by 
the same prompt and complete relief. 

Perforation of the Ccecum. — When, however, perforative ulceration 
is progressing, the symptoms follow a diff'erent course. The constipa- 
tion may be relieved and the vomiting cease, but the local symptoms 
persist, until the rupture of the bowel leads either to speedily fatal 
peritonitis, or to the effusion of fecal matter mixed with the products 
of inflammation into the pericoecal tissue. When this latter event oc- 
curs, the constitutional symptoms soon indicate the occurrence of sup- 
puration, and hectic irritation, with rigors or marked chills succeeded 
by drenching sweats, colliquative diarrhoea, rapid prostration and ema- 
ciation, with a dry brownish tongue and feeble running pulse, soon 
appear. Despite the desperate character of these symptoms, how- 
ever, recovery may take place if the abscess points externally in the 
waj' already described, and does not open into the peritoneal cavity. 
It is necessary to be aware that the approach of a fecal abscess to the 
surface is not attended with the appearances which usually accompany 
the pointing of an abscess. Thus, instead of the skin becoming tense, 
prominent, and reddish, with a distinct sense of fluctuation present, 
the surface becomes doughy and dark-colored, and upon palpation a 
distinct sense of emphysematous crepitation is often obtained. Upon 
incising such a point, a discharge of fetid gas and grumous matter fol- 
lows the puncture, and this peculiarity has more than once led surgeons 
to believe that they had opened a knuckle of intestine. 

Perforative Ulceration of the Appendix. — The symptoms of this 
disastrous condition closely resemble those of perforation of the ante- 
rior part of the coecum. They are, however, often even more acute, 
the pain is sudden and violent, and a distinct tumor is more uniformly 
present; while, on the other hand, the symptoms of obstruction of the 
intestine are not so well developed. Constipation and vomiting are 
not constant in the early stage, and at a later period spontaneous diar- 
rhoea may appear, but without any favorable result. The perforation 
of this part is, as already said, far more apt to be followed by general 
peritonitis; and, indeed, so far as we know, there is but one well-authen- 
ticated case on record of recovery after this accident, which was pub- 
lished by one of ourselves in the Proceedings of the Pathological Society 
of Philadelphia. (See Amer. Jour. Med. Sciences^ vol. liv, July, 1867, p. 
145.) 

Perityphlitis, or inflammation of the pericoecal tissue, when it does 
occur independently of typhlitis, is ushered in by pain, with deepseated 
tenderness in the right iliac region. There is also some fulness of this 
part, but not the formation of a distinct tumor, as may frequently be 
detected in typhlitis. There are usually colicky pains in the abdomen, 
with either constipation or diarrhoea, and with a moderate degree of 



458 DISEASES OF THE C(ECUM AND APPENDIX C(ECI. 

febrile excitement. This disease, when judiciously treated, frequently 
seems to terminate in resolution; when, however, suppuration occurs, 
the symptoms will approximate those given above, and the abscess 
which forms may discharge itself externally, into the bowel or into the 
peritoneal cavity. 

Duration. — Many attacks of acute tj^phlitis, when promptly and 
judicioush' treated, yield on the second or third day; though the case 
is often prolonged to the ninth or twelfth day. and, in violent attacks, 
it may be man}^ weeks before all local tenderness in the ccecal region 
passes away, and the function of the bowel is again completely restored. 

When perforation of the coecum occurs, the after-duration of the case 
depends entirely upon the point of perforation. If the ulcer have pen- 
etrated the anterior wall, general peritonitis is usually excited, and 
death results in less than forty-eight hours. But if, on the other hand, 
the posterior wall be perforated, a fecal fistula may be formed, and con- 
tinue open for very many j^ears. The duration of perforative ulcera- 
tion of the appendix varies considerably. In 3 cases in children, ob- 
served b\^ ourselves, the duration was respectively seven, nine, and 
fourteen daj'S, with a mean often da^'s. 

In 11 cases, at all ages, in which the duration is distinctly stated, the 
mean duration was nine days, the extremes being two and a half and 
twenty-nine days. 

Bamberger, however, gives the duration of seven cases, occurring at 
various ages, at from twenty to fifty days, with a mean of thirty-one 
days. It is probable, however, that this last mean is rarely attained 
in cases occurring in children. 

Prognosis. — IS'early all cases of simple acute typhlitis, without per- 
foration of the bowel, recover under proper treatment. Indeed, there 
are no cases on record of acute typhlitis proving fatal, in which post- 
mortem examination did not show the existence of perforation of the 
coecum or appendix. 

When the coecum has become the seat of chronic inflammation, how- 
ever, death may result, either from the sudden development of acute 
peritonitis, without perforation of the bowel, or from such contraction 
of the coecum as finally to lead to obstruction of the intestine. 

When perforation of the coecum does not prove speedily fatal from 
peritonitis, but leads to the formation of an abscess in the iliac fossa, 
the prognosis of the case depends, in a considerable degree, upon the 
course taken by this abscess. Dupuytren regarded the reopening into 
the bowel as the safest termination of an iliac abscess, and the opening 
upon the surface of the body as almost universally fatal. Further ex- 
perience has confirmed the truth of the first portion of this opinion, but 
has also established the fact, that almost one-half of the abscesses open- 
ing externally recover. 

Perforation of the appendix vermiformis is invariably fiital, so far as 
our experience goes, if we except the case before referred to, where, in 
an old man about whose past history nothing could be learned, we 



DIAGNOSIS. 459 

found the appendix converted into a solid fibrous cord, with a small 
opening, near the free extremity, leading to its centre. 

Diagnosis. — The general diagnosis of most of these conditions is not 
attended with much difficulty. We have already mentioned that simple 
excessive distension and impaction of the coecum is sometimes attended 
with severe pain, some tenderness, constipation, and even vomiting, 
and that these symptoms are relieved upon free action of the bowels 
being secured, AYe do not have here, however, the sudden attack 
occurring in a state of perfect health, as in typhlitis, nor the marked 
febrile symptoms; nor are the local signs in the right iliac fossa, 
and especially the peculiar, exquisite sensitiveness, nearly so well de- 
veloped. 

Inflammatory disease, in connection with the right ovary, with local 
peritonitis, is unquestionably sometimes mistaken for typhlitis. The 
local symptoms in the former affection are, however, lower down in the 
abdomen than is usual in typhlitis ; there is not the well-defined tumor 
nor the obstinate constipation; and, in addition, there is generally the 
history of some menstrual trouble, or the attack occurs in immediate 
connection with the period of menstruation. 

Pain in the coarse of the last dorsal nerve may arise from spine dis- 
ease, or, in the course of the genito-crural nerve, from the passage of a 
renal calculus, and, according to Hahershon, be confounded with coecal 
disease. It is evident, however, that most of the characteristic symp- 
toms of typhlitis would be absent, whilst a careful investigation of the 
case would probably educe more symptoms of the existing trouble. 

The diagnosis of typhlitis from intussusception, an affection which 
presents many features of resemblance, will be fully considered in the 
article devoted to this latter disease. 

Ulceration of the coecum or appendix ma}' be suspected, if the violent 
pain and the exquisite tenderness persist in the right iliac region, after 
the other symptoais of an acute attack of coecal disease, especially the 
vomiting and constipation, have been overcome. Ulceration of the 
coecum is much more apt to have been preceded by bowel complaint 
for some time; it is also much more rare than ulceration of the ap- 
pendix. 

In cases where we are consulted only after perforation has taken 
place, with the production of a fecal abscess, we must endeavor, by 
obtaining a most accurate history of the case, to establish the presence 
or absence of symptoms of inflammation of the coecum at the begin- 
ning. And further, care must be taken to exclude the following con- 
ditions, all of which may at times simulate iliac abscess, namely : psoas 
abscess, or abscess connected with caries of the pelvic bones; abscesses 
in the walls of the abdomen, with local peritonitis, resulting from 
blows; suppuration originating in connection with the right kidney or 
its envelope; and finally, some cases of disease of the right hip-joint. 

The diflerential diagnosis of these affections of the coecum and ap- 
pendix from one another is as yet scarcely possible. The following- 
general remarks contain, perhaps, all that can be surely advanced : 



460 DISEASES OF THE CCECUM AND APPENDIX CCECI. 

Simple inflammation of the appendix presents sj^mptoms of even 
greater acnteness and severity than those of simple coecitis, and which 
do not subside so promptly after the bowels have been freely acted 
upon. 

In ulcerative disease, both of the coecum and appendix, the symptoms 
also persist after the constipation and vomiting have j-ielded. 

Ulceration of the coecum, however, is rare, and is apt to be preceded 
by S3^mptoms of bowel complaint. Whilst ulceration of the appendix, 
on the other hand, is often terribly acute, advancing from a state of 
apparent perfect health to perforation and death in forty-eight hours; 
it is also much more frequently attended with a distinct tumor in the 
right iliac region. 

Treatment. — The indications for treatment in the acute stage of 
typhlitis are clearly to reduce the local inflammation of the peritoneum 
and intestine, to relieve the pain and tenderness, and to secure free and 
natural action of the bowels. At the same time, all perturbating and 
strongly reducing treatment is forbidden, by the knowledge that the 
attack is frequently caused by an irritating foreign body : and that, in 
a certain number of cases, perforation will occur, in which event the 
onl3^ hope of recover}^ often rests upon the adhesions which have been 
formed during the early stage, and upon the vigor of the constitution 
to resist a prolonged and exhausting process of suppuration. 

Depletion. — The local abstraction of a few ounces of blood hj the ap- 
plication of leeches to the coecal region, should be practised in acute 
cases. This measure, while it does not seriously reduce the strength of 
the patient, relieves the pain and tenderness, and probably facilitates 
the action of the internal remedies employed. Beyond this degree, 
however, depletion is injurious, or, at least, unnecessarj'. 

Purgatives. — The experience of all observers agrees in condemning 
the use of powerful, irritating purgatives at anj^ stage of typhlitis. In 
the early stage, they aggravate the pain and inflammation, increase or 
establish vomiting, and frequently fail entirely in their object; while, 
on the contrary^ the constipation which will resist the strongest, most 
drastic purgatives, will quickly yield to mild, saline, or vegetable 
laxatives. 

It is a good plan to combine a small amount of opium with the lax- 
ative ; since, so far from counteracting its operation, it appears, by 
allaying the intense sensitiveness of the bowel, to promote its painless 
and thorough action. 

Burne recommends highly the following laxative draught, the dose 
of which is arranged for an adult : 

R. — Sodoe Sulphatis, gj, 

Tr. Opii, gtt. V. 

Inf. Semite, f^j. 

Ft. sol. S.— Kepeat every four hours until the bowels are freely moved. 

We have ourselves been led by experience to rely upon the combina- 
tion of comp. ext. colocynth with opium, given in small and frequently 



TREATMENT. 461 

repeated doses. Thus, for a child of from five to eight years, the fol- 
lowiDg pill may be prescribed : 

R. — Pulv. Opii, gr. ijoriij. 

Ext. Colocynth. Comp., .... gr. xij to xviij. 
Ft. mas et div. in pil. No. xxiv. 
S. — One every three or four hoars until free action of the bowels is secured. 

Enemata, — The actioD of these laxatives may be furthered by the 
administration of large enemata, which may consist either entirel}^ of 
tepid water, or of water containing a small proportion of some stimu- 
lating or laxative substance, such as soap, molasses, or castor oil. In 
cases where the irritability of the stomach precludes the administra- 
tion of laxatives by the mouth, enemata become especially important, 
and at times their use will be followed by the most happy results, the 
irritating contents of the coecum being brought away with almost im- 
mediate relief to the most threatening symptoms. 

Mercury. — It is difficult to support the practice of giving this drug in 
typhlitis. In the early stage, indeed, when it may be supposed that the 
intestinal canal contains irritating ingesta and secretions, a small dose 
of calomel or blue pill may be administered; and, in a large number of 
the successful cases on record, this was done. It is not, however, at 
all necessary. Beyond this, the further use of mercury appears to us 
injurious, since, if it be given until any constitutional effects are pro- 
duced, it must have a tendency to prevent the formation of those strong 
adhesions which constitute the sole chance of recovery in case of per- 
foration of the appendix or the anterior wall of the coecum. 

Opium. — We have already mentioned the way in which opium is most 
advantageously given in this affection, in combination with the laxative 
employed. Its use is absolutely called for, and the violence of the local 
symptoms, the pain and exquisite tenderness, form the best guide as to 
the amount required. 

Poultices and Counter irritants. — In case even the local abstraction of 
blood appears undesirable, resort should be had to the frequent appli- 
cation of mustard plasters or turpentine stupes to the coecal region. 
Hot fomentations or light poultices, to which some sedative substance 
may be addcJ, should be kept constantly applied to the abdomen. 

Vomiting when present, should be allayed by counter-irritation, bj^ 
swallowing small fragments of ice, by carbonated drinks, hydrocyanic 
acid, or any other suitable remedy. 

The diet during the early stage should be fluid, and unirritating in 
character. 

When the persistence of the symptoms leads us to apprehend the 
presence of ulceration, either of the coecum or appendix, all depletory 
and perturbating treatment should be abandoned, and we should limit 
our efforts to the relief of pain, by the use of opium and the continued 
application of poultices; to regulating the functions of the intestinal 
canal, and to the sustentation of our patient's strength. 

If perforation has occurred, without the speedy development of 



462 INTUSSUSCEPTION. 

general peritonitis, our attention should be mainly directed to support- 
ing the system during the long and exhausting process of suppuration 
which must ensue. For this purpose a generous, though digestible diet, 
with as much stimulus as appears necessary, should be enjoined; and 
resort may also be had to the various tonics, as quinia or the prepa- 
rations of bark. If a tumor forms, and it becomes evident that the 
abscess is tending to discharge externally, its approach to the surface 
should be encouraged by poulticing; and the moment an emphysema- 
tous condition of the skin is detected at any point, a free incision should 
be made, and the discharge of matter furthered by the introduction of 
a sponge-tent or a pledget of lint, and the application of a poultice. 

In those unfortunate cases where the perforation of the bowel has 
been followed by general peritonitis, all treatment is unavailing. Our 
main reliance must, however, be placed upon the exhibition of opium, 
and the use of counter-irritation. 



ARTICLE Yl. 

INTUSSUSCEPTION. 



Definition; Synonyms; Forms; Frequency. — Obstruction of the in- 
testinal canal, from one or another of the numerous causes capable of 
producing it, is an accident liable to occur at all periods of life. But 
the variety of it which forms the subject of this article is of rare occur- 
rence excepting in early childhood. It has been called ileus, volvulus, 
miserere mei ; but is best known under the descriptive names of intus- 
susception or invagination of the intestines. It consists in the passage 
or introduction of one portion of intestine within another, as a small 
tube might slide into a large one, or, to borrow a familiar illustration, 
as the end of a glove finger may be pushed back upon itself into the 
glove. This simple invagination, however, is not the only element 
present, for in order that the symptoms of intussusception should be 
produced, it is necessary that the included portion of bowel should ha 
so incarcerated and constricted as to give rise to more or less complete 
intestinal obstruction. This has led to a very just division of intussus- 
ceptions into such as are slight, unattended by inflammation, or spas- 
modic; and such as are grave, or attended by inflammation and incar- 
ceration. The slight form of invagination is found very frequently at 
autopsies of children who have died of other diseases, and in whom 
during life there was no symptom of disturbed function of the aliment- 
ary canal : it is in all probability produced in the death agony. 

M. Louis states that the greater part of 300 children dying during 
the period of dentition at the Salpetriere, had 2, 3 or even 4 volvuli 
without inflammation. 

Baillie, Cheyne, and Billard speak of such intussusceptions as being 



ANATOMICAL APPEARANCES. 463 

frequently found at the autopsies of children ; and Burns, as quoted by 
Gorham.^ gives the results of the autopsies of 50 children M'ho had died 
from diarrhoea, in every one of which they were found. This species 
of invagination in children occurs almost exclusively in the small in- 
testine; the invaginated part is usually of no considerable length; and 
the very slightest traction suffices to restore it. 

The grave form, on the other hand, differs from this alike in the very 
positive symptoms by which its presence is announced, in the condition 
of the parts involved, and in the part of the bowel affected ; and as the 
form first mentioned scarcely deserves to be called a disease, it is to the 
latter alone that the following remarks are addressed. 

Frequency. — Although numerous well-authenticated cases of intussus- 
ception occurring in adults are on record, statistics prove that it is 
relatively much moi'e frequent during the first four years of life. 
Thus of 100 cases given by Duchaussoy^ in which the age is men- 
tioned, there were 31 under 4 years of age, 6 between 4 and 1(1 j^ears, 
and 63 adults. Smith's^ tables go to show that "this complaint is rare 
under the age of 3 months, and that the period of greatest frequency is 
from the thii-d to the sixth month of life, the maximum number being 
at the fourth month." Thus there were 11, of the 50 cases collected 
by him, at the age of 4 months, or 21 in all between 3 and 6 months 
inclusive; 8 from 6 months to 1 year; and only 18 between the ages of 
1 and 12 years. 

We must, however, call attention to the rarit}^ of this disease at any 
age among us; for although, in the course of a very extensive practice 
among children in this city, we have met with several well-marked 
illustrations of the various forms and terminations of intussusception, 
it has been one of the rarest occurrences in our experience. 

Anatomical Appearances. — Intussusceptions, anatomically consid- 
ered, may be divided into descending or progressive, and ascending 
or retrograde, according to the direction which the invaginated por- 
tion takes; and into central or lateral, according as the entire intes- 
tine, or but one wall, is invaginated. Lateral invaginations, how- 
ever, are exceedingly rare, occurring but twice in 187 cases collected 
by Duchaussoy. 

Excepting when invagination occurs as a complication of some other 
affection, it is almost invariablj' of the descending form. Thus, of Du- 
chaussoy's 137 cases, only 16 were retrograde, all of them being com- 
plicated; and Haven gives but 3 instances of ascending intussusception 
out of 59 cases. 

It is a matter of considerable importance to determine what is the 
most frequent seat of intussusception in children. Eilliet and Barthez* 

1 Guy's Hosp. Keports, Lst series, vol, iii, 1838, p. 330. 

2 Duchaussoy, Mem. de I'Acad. de Med., voL xxiv, p. 97 (New Syd. Soo. Year- 
Book, 18o3, p. 294), 

3 Smith, Statistics of Intussusception in Children (Am. Jour. Med. Sci., vol. xliii, 
1862, p. 17). 

■* Mai. des Enfants, 2eme ed, torn, i, p. 806. 



4G4 INTUSSUSCEPTION. 

declare that in infants the small intestine is almost never the seat of 
intussusception, but that ordinarily it is the lower end of the ileum 
^vhich is invaginated into the large intestine. The reasons for this 
are found in the anatomical conditions of the intestines in infancy: 
the adhesions of the coecum to the right iliac fossa being much more 
limited and less powerful than in later life; and the muscular coat of 
the coecum being but slightly developed in childhood, a circumstance 
which must also tend to favor the passage of the lower end of the ileum 
through the valve. 

The statistics of Duchaussoy and Smith confirm this opinion; as of 
31 cases of simple descending intussusception in children under 4 years 
of age, collected by the former, the large intestine alone, or both the 
large and small, formed the intussusception in all but 4 cases; and 
Smith states that he has found no exception to Eilliet's remark, as 
regards early infancy. In children above the age of 2 years, fatal in- 
vagination in the small intestines may occur in rare cases. In a few 
cases also, the ileum has preserved its normal relations to the ileo- 
coecal valve, the coecum being the first part inverted, and drawing after 
it the lower end of the ileum. 

An intussusception, then, is made up of three folds of intestine : 
1st, The inner, or contained part, which in descending intussuscep- 
tions is always in the natural direction; 2d, The middle, which is a 
reflection of the inner, and passes in a direction contrary to the intus- 
susception; and 3d, The outer, containing part or sheath, which is in 
its natural position, and in the direction of the intussusception. AYe 
find, therefore, the mucous membrane of the middle and outer parts in 
apposition; and the peritoneal investment of the middle and inner parts 
in contact. 

The amount of intestine invaginated and the condition of the parts 
depend, in great measure, upon the duration of the case. If death 
takes place early, only a small portion of the ileum may have passed 
the valve; but as the case progresses, the tenesmus or the active peri- 
staltic action of the outer part, brings down more and more of the ileum 
■with its accompanj^ing mesentery, until finally, the constriction of the 
ileo-coecal valve preventing the descent of any more of the ileum, the 
coecum is inverted and forced into the ascendino- colon. This in turn 
may be invaginated in the descending colon and rectum, until not un- 
frequently a portion of the invaginated intestine protrudes from the 
anus. In rare cases, the w^hole invaginated mass descends into the in- 
testine below^, thus forming a double intussusception of great thickness. 
It has occurred, in a few rare cases, that the amount of constriction 
was so slight that the intestine remains pervious to a certain extent; 
so that life has been protracted for many weeks, and death has finally 
ensued only from exhaustion. But ordinarily the parts are in the fol- 
lowing condition : the intestine above the point of constriction is dis- 
tended with gaseous and fecal contents, and more or less discolored 
from congestion of its walls. It is rare, however, to find any evidences of 
enteritis either here or in the intestine below the intussusception, which 



ANATOMICAL APPEARANCES. 465 

is generally pale and contracted. The invaginated portion itself, at the 
upper part, where it seems to plunge into the containing portion of the 
intestine, presents a series of concentric circular folds. The walls of 
the bowel thus incarcerated are thickened and infiltrated; their serous 
investment either deeply injected or discolored by congestion and 
ecchymosis, so as to be of a deep blackish-red color; and frequently 
evidences of local peritonitis are present. The mucous membrane in 
cases of short duration may be merely thickened and injected, but more 
frequently it is turgid from congestion, ecchymosed in points, and shows 
the effects of violent inflammation by its unequal roughened surface, 
presenting either ulcerations or grayish false membranes The capil- 
laries of the constricted portion become greatly distended, so that, 
especially in young children, in whom the vascular rete of the intes- 
tines is remarkably rich, whilst the tissues are delicate and yielding, 
they frequently rupture, filling the invaginated intestine with bloody 
and 23roducing bloody discharges. 

If the case is protracted and the powers of life sufficient, when treat- 
ment has not sufficed to reduce the intussusception, nature endeavors to 
effect a cure by eliminating the invaginated portion. The incarcerated 
bowel becomes gangrenous, a line of separation forms, union and cica- 
trization take place between the part of the bowel above the intussus- 
ception and the upper part of the containing intestine, and the invagi- 
nated portion is discharged per anum. This process of elimination is 
extremely rare in infants; but it is stated by Eilliet to be the ordinary 
method of cure in children in their second infancy. In 59 cases re- 
ported by Haven,^ of all ages, discharge of the intestine per anum took 
place 12 times, with recovery in all but two cases. The average length 
of intestine passed in these cases was 23 J inches; in the two fatal cases, 
the portions passed were respectively 39 and 44 inches long. The earli- 
est age at which w^e have met with this process of cure, is at 13 months 
in a case reported by M. Marage. 

In the report of the Proceedings of the Pathological Society of London^ 
vol. xiii, a specimen is described by Dr. Hare, where this process had 
taken place. The patient was a female, 41 years of age, and her death 
resulted from tubercular disease three months subsequently to the pas- 
sage of the sphacelated bowel^ " which was 6J inches in length, of a very 
dark pUrplish-gray color: it formed a perfect cylinder, but the intestine 
was turned inside out, the exterior of the specimen, as voided, being the 
mucous membrane, and the interior of the cylinder being the peritoneal 
covering of the intestine." 

At the autopsy, at the point where the invaginated portion had been 
separated, about fifteen inches above the coecum, the line of union was 
found running obliquely across the intestine, ^' but the union was so 
perfect that it could scarcely be detected except by holding up the in- 
testine between the eye and the light, when the thinness of the intes- 
tine clearly pointed out the line or seam where the union had taken 

1 Haven on Intestinal Obstruction, Amer. Jour, Med. Sci., vol. xxx, 1855, p. 351. 

30 



466 INTUSSUSCEPTION. 

place. Exactly at the point of union the intestine was notably nar- 
rower than natural; but the intestine above this point was a little di- 
lated." 

We have recently had an opportunity, through the courtesy of Prof. 
A. Stille, of studying a specimen in which a similar process of cure had 
been effected. The patient was an adult^ who died of some chronic dis- 
ease, and no history could be obtained of the occurrence of the attack 
of intestinal obstruction, or of the discharge of the sphacelated portion 
of bowel from the anus. The specimen, however, presented appear- 
ances which left no doubt that invagination of a portion of the ileum 
had occurred, that the invaginated portion had sloughed away, and 
that union had taken place between the intestine, just above the intus- 
susception, and the upper part of the sheath, so as to preserve the con- 
tinuity of the bowel. The axternal surface ]3resented a marked con- 
striction encircling the intestine, due to the entrance of the upper part 
of the bowel into the sheath. There was a layer of organized lymph 
investing the peritoneum at the line of junction, and firmly uniting the 
two serous surfaces. Upon laying open this part of the ileum, a narrow 
rim of indurated tissue, evidently the altered intestinal wall, projected 
downwards into the intestine from the line of constriction, and formed, 
as it were, a perforated diaphragm across the calibre of the bowel. 

We thus see that even when the slough is cast off, and the patient 
recovers from the intussusception, the cure is not always permanent, 
since in a small proportion of cases there may be serious contraction of 
the bowel, caused by the ensuing cicatrization. 

In addition to the modes of recovery already adverted to, namely? 
the reduction of the intussusception either by the movements of the 
bowel itself or by the remedial measures adopted, and the elimination 
of the invaginated portion, there is still a third mode possible, in which 
the intestine remains invaginated, but by agglutination of the outer 
folds, becomes pervious, and undergoes such atrophy and contraction 
as not to interfere materially with the functions of the bowel. Eilliet 
and Bartbez, as well as other Continental authors, speak of this as of 
occasional occurrence, but we have not found any well-authenticated 
cases recorded. 

There are few morbid changes found in intussusception excepting 
those pertaining to the intestines. It is, however, worthy of mention, 
that in some cases the invaginated mass appears to produce serious 
compression of the large vessels of the abdomen. 

Causes -, Age. — We have already given the statistics which prove that 
intussusception is relatively very much more frequent during the first 
four years of life, the period of maximum frequency being between the 
third and sixth months. It is very rare before the age of three months. 
All forms of invagination, however, do not occur with equal frequency 
at these various ages. During early infancy, for the anatomical reasons 
already assigned, the almost invariable seat of the invagination is the 
lower end of the ileum and the upper part of the large intestine; while. 



CAUSES. 467 

after the age of two years, invaginations of the small intestine alone, 
though still very rare, may occur. 

Sex. — All statistics agree in giving a majority of males over females, 
at least in the proportion of 2 to 1 ; while in some tables the propor- 
tion is as high as 7 to 1 ; thus Eilliet and Barthez collected 25 cases, of 
which 22 were boys. 

Previous Condition. — In by far the majority of cases, intussusception 
in the infant occurs as an idiopathic affection, appearing during perfect 
health. In children over one or two years of age, however, it is much 
more apt to be preceded by some disturbance of the alimentary canal, 
as constipation, diarrhoea, dj-sentery, or even by symptoms of imper- 
fect obstruction of the intestines. 

Intussusception may also occur during the course of other diseases, 
as in a case quoted by Eilliet from Legoupil, where the invagination 
appeared during the progress of variola; the child, 4i years old, re- 
covered. 

Exciting Causes. — External violence^ as blows upon the abdomen, or 
sudden jerking of the child's body, as in tossing it in the arms, are as- 
signed as the probable exciting cause of a certain number of cases. It 
has been supposed, also, that violent fits of coughing or screaming, or 
strong straining at stool, have produced invaginations, especially in 
ver}' yo^ii^g children. 

Improper alimentation and sudden changes of diet appear to act 
quite frequently as efficient causes; thus in a case reported by Gorham, 
occurring in a healthy infant of four months old, the only assignable 
cause was the administration of panada for three days preceding the 
attack. It is, however, frequently impossible to assign any plausible 
reason for the sudden production of severe intussusceptions. 

Granting, however, the presence of any of these causes, the question 
still remains as to the exact mechanism of the invagination. Accord- 
ing to Gorham, "it is necessary to the production of an intussusception 
that there should be either : 1st, A contraction of the part to be intus- 
suscepted ; or 2d, A dilatation of that part which is to be the outer fold; 
or 3d, A natural and sudden inequality of calibre of some portion of 
the intestinal tube. The first of these conditions may be produced by 
spasm; the second by flatus; whilst the third is always present at the 
termination of the ileum in the coecum." It is at this point, accord- 
ingly, that intussusception most frequently occurs, and, from the ana- 
tomical arrangement of the parts making it very difficult for restitution 
to occur, puts on its most dangerous and fatal characters. 

The invagination having once begun, its increase and persistence 
are probably due to the active peristaltic action of the outer fold, aided 
by the spasmodic contractions of the diaphragm and abdominal mus- 
cles, causing the powerful tenesmus so frequently observed. 

There is one more question in regard to the etiology of this affection, 
about which various opinions have been expressed; whether, namely, 
enteritis holds the relation of cause or effect to intussusception. Eilliet 
and Barthez appear to us to have given it its true importance in stat- 



468 INTUSSUSCEPTION. 

ing that it sometimes plays one part and sometimes the other. We 
have already seen that, though in many cases intussusception occurs 
suddenly in full health, there are a sufficient number of instances where 
the attack has been preceded by symptoms of intestinal irritation or 
inflammation, to make it clear that at times enteritis acts as a predis- 
posing or determining cause. And, on the other hand, the pathological 
anatomy of the disease, showing the inflammation of the bowel to be 
limited to the immediate vicinity of the invagination, and to be the 
more intense as the constriction is tighter, proves that enteritis fre- 
quently appears as a result of intussusception. This becomes especi- 
ally evident in those cases where the disease has been caused by exter- 
nal violence, and where after death the above conditions have been 
noticed. 

Symptoms; Duration; Terminations. — The principal symptoms of 
intussusception are furnished by the gastro-intestinal apparatus; and, 
towards the termination of unfavorable cases, by the nervous system. 
We have seen that a considerable difl'erence exists in the seat of the 
invagination at different periods of childhood, and in examining the 
symptoms we find a corresponding disparity, according as the intus- 
susception occurs in the first infancy, under the age of two years, or in 
the second infancy, between the second and sixth year. These points 
of difference will be mentioned as each symptom is discussed. 

The most important and characteristic symptoms are : vomiting, con- 
stipation, and bloody discharge from the anus; abdominal pain, tenes- 
mus, and protrusion of the intestine, the presence of a tumor in the 
abdomen, and tympany. 

Vomiting is an almost constant symptom, being present in about 95 
per cent, of the cases. Very rarely the gastric disturbance amounts 
only to nausea, but nearly always vomiting sets in early in the attack 
and persists, despite all treatment, until either the invagination is re- 
lieved, when it promptly ceases; or until the approach of death. Quite 
frequently it ceases a day or two before the fatal event occurs. The 
matters vomited at first consist of the ingesta, the stomach rejecting 
everything taken into it; soon, however, they become mixed with mu- 
cus and bile. In very j^oung children it is rare for stercoraceous vom- 
iting to occur, but in those who are above two years of age it may oc- 
casionally be present. In Smith's 50 cases, it occurred in three at the 
respective ages of 3^ 6, and 11 years. 

The\;ondition of the bowels is generally one of obstinate constipation^ 
so far as the passage of fecal matters is concerned. It is not unusual 
for one natural abundant stool to occur after the intussusception begins, 
but this is succeeded ■ by constipation. It is only in those very rare 
cases where the invaginated portion remains pervious, that a small 
amount of fecal matters finds its way into the stools. 

The discharges which, however, do take place almost invariably in 
intussusception in children are due to the rupture of the capillaries of 
the constricted bowel, and consist of blood mixed in varying propor- 
tions with mucus and serum. It is rare for the blood to be so deficient 



SYMPTOMS. 469 

that the discharo-es resemble the gelatinoid mucous discharges of dys- 
entery, merely streaked and tinged with blood, whilst, at times, the 
blood is in such excess as to appear pure, and to constitute a true in- 
testinal hemorrhage. This symptom, the true value of which was first 
recognized by Gorham and Clarke,^ is of more uniform occurrence in 
children under two years, on account of the greater ease with which 
the intestinal capillaries give way in infancy. Thus of 26 children 
under one year of age, bloody evacuations occurred in 23, usually sev- 
eral times in the twenty-four hours; in 2 of the 26 there is no record of 
this symptom, and in 1 only is it recorded as absent. In case No. 2, of 
Mr. Gorham's table, a child of 3i months passed within a few hours 
more than a teacupful of fluid blood. In older children, on the other 
hand, bloody discharges occur less frequently; thus Smith records 18 
cases of invagination between one and two years, in only 6 of which it 
is stated that there were bloody motions. 

We have already mentioned the various ways in which recovery 
takes place, and when elimination of the invaginated portion is about 
to occur, which is almost exclusively limited to cases occurring in the 
second infancy, the stools become highly fetid, contain more or less 
blood, are blackish or brownish in color, and are soon accompanied by 
the discharge of the slough. The interval elapsing between the incep- 
tion of the attack and the discharge of the portion of bowel, varies con- 
siderably in different cases, but seems to be less in childhood than in 
adult age. Thomson states that in adults the elimination takes place 
in the majority of cases within thirty days; and in one of his cases it 
occurred as early as the sixth day. In children the interval rarelj^ ex- 
ceeds twelve days; and the average of all recorded observations would 
seem to fix about nine days as the usual time. 

Abdominal pain is among the earliest and most constant symptoms at 
all ages. During the early part of the attack, it appears in paroxysms; 
and may be detected even in the youngest children, by the violent 
paroxysmal screaming, and contortions of the limbs and trunk. At the 
commencement, the abdomen is generally relaxed, supple, and indolent; 
and this condition may remain until death, perhaps because the con- 
striction in some cases is not complete and allows the passage of gas. 
But after a few days, there is apt to be more or less continuous pain 
and soreness on pressure in the part of the abdomen corresponding to 
the invagination, due to the local enteritis and peritonitis. This may 
or may not be accompanied by tympany and diffuse tenderness of the 
abdomen ; but, as a general rule, intussusception in very young children 
is not attended by the great distension and marked symptoms of general 
peritonitis which frequently appear in intestinal obstruction in adults. 
In children over two years of age, the abdominal symptoms are more 
apt to indicate peritonitis. In a considerable proportion of cases, tenes- 
mus occurs and adds much to the suffering. It does not appear so early 
as the abdominal pain, and generally ceases a few days before death. 

1 London Lancet, January, 1838. 



470 INTUSSUSCEPTION. 

Tumor. — It would appear natural that when a considerable intussus- 
ception has taken place, the knot formed at the point of obstruction 
should be readily detected through the abdominal walls. And yet the 
cases on record show that this tumor is recognizable in not more than 
two or three out of every ten cases. When it can be detected, it is 
generally found in the left iliac region, varying in size from a walnut 
to a large goose-egg, and giving the sensation of a solid, but doughy 
and compressible mass. It is ordinarily quite movable, and percussion 
elicits a dull note over its position. 

Another symptom depending upon the displacement of the intestine, 
to which considerable importance has been attached in the diagnosis of 
invagination in the adult, is a depression of the abdomen at a point cor- 
responding to the displaced intestine, and a fulness at the correspond- 
ing point on the opposite side. Experience has shown, however, that 
but little value can be attached to this sign in young children, on ac- 
count of its great rarity. 

We have seen that thejDresence of a tumor in the abdomen is far from 
an invariable sign of intussusception, and the same remark applies to 
the protrusion of the invaginated bowel from the anus, a symptom to which 
very different diagnostic value has been attached by different authors. 
It is stated by some to be almost never present, but we have found it 
recorded particularly in six of Smith's cases, the same number in which 
an abdominal tumor was present in the same series; and in three other 
cases, although no tumor protruded from the anus, the invaginated mass 
was readily felt by examination per rectum. 

When the bowel protrudes, it forms an oblong tumor, at times even 
two inches in length, much congested from the constriction, and smeared 
with blood and mucus. 

When we pass from these positively diagnostic symptoms, we find 
little elsewhere characteristic of the disease. The tongue is normal 
until inflammatory action sets in, when it often becomes dry and brown; 
the appetite is impaired or absent, and the thirst is generally but moder- 
ate. Eilliet and Barthez call attention to the importance of this last 
symptom in a diagnostic point of view, as well as to the fact that the 
emaciation is usually not so marked as in other acute diseases of equal 
duration and severity. 

The amount of febrile action is generally slight in infancy; the sur- 
face, cool at first, may at times become hot, or is alternately hot and 
cold, and as death approaches remains continuously cold. The pulse 
soon becomes frequent, though small and feeble. There is no marked 
disturbance of respiration. 

In older children there is apt to be more febrile action, the skin being 
hot until late in the attack, and the pulse frequent and more full. The 
physiognomy of the little patient is greatly altered from the commence- 
ment of the attack. The eyes are dull and languid, sunken in their or- 
bits, and surrounded by discolored areolae; the countenance is expres- 
sive of the most profound prostration, so as to have elicited a comparison 
to the physiognomy of cholera patients. 



PRoaNosis. 471 

Almost all cases, at whatever age, present symptoms of marked dis- 
turbance of the nervous system, as great restlessness, indescribable 
malaise, sharp cries, and, toward the close of the case, profound pros- 
tration. But in infiincy, in addition to these symptoms, the case is 
more apt to present an attack of convulsions, either as one of the earliest 
symptoms, or toward death, alternating with coma. 

Duration. — It is necessary to distinguish here between cases occurring 
during extreme infancy, when we cannot hope for elimination to take 
place, and those in more advanced childhood. In early infancy, when 
the attack is about to take a favorable turn, the symptoms usually yield 
in from two to four days, owing to reductian of the invagination. In 
fatal cases, death occurs within five days, as the rule. In some cases, 
however, where the constriction was not complete, life has been pro- 
longed even for six weeks. 

In second infancy, where the constriction is complete, and the result 
fatal; death occurs within seven or eight days in the vast majority of 
cases. But when elimination is to result, the case is more protracted, 
and complete recovery is postponed to the third week. Thus, in 7 cases 
out of Smith's statistics, which resulted favorably by sloughing, the 
ages were 5, 6, 6, 9, 11, 12, and 12 years respectively; and the separa- 
tion of the invaginated portion took place between the ninth and twelfth 
days, with an average of nine and a half days. After the discharge of 
this, which is soon followed by the fetid, brownish-black stools already 
described, the symptoms rapidly disappear, and in one or two weeks 
the cure is complete; so that, if we can carry a patient, advanced be- 
yond the first infancy, through the first week of the attack*without 
too much exhaustion, we may each day look for the discharge of the 
invaginated bowel, the restoration of the function of the intestines, and 
ultimate recovery. 

Terminations. — We have already described the favorable modes of 
termination, namely, by the subsidence of the intussusception, either 
spontaneously or as the result of treatment; by restoration of the 
calibre of the bowel by sloughing of the invaginated bowel, and union 
and cicatrization of the divided edges; and finally, hj agglutination of 
the outer layers of the invaginated portion with subsequent thinning 
and atrophy, thus rendering the intestine pervious, although the in- 
tussusception remains. 

In those cases in which death takes place very early, as on the first 
or second day, it is frequently produced by cerebral congestion or an at- 
tack of convulsions. In the majority of cases, however, it occurs some- 
what later, and is preceded by a state of collapse. Even in those cases 
where the constriction is not at first complete, and where there are 
daily feculent evacuations for a time, death is apt to occur from ex- 
haustion, or from the invagination becoming more extensive and s^^mp- 
toms of complete obstruction arising. 

Prognosis — A single glance at the character of the lesion and the 
accompanying phenomena, suffices to assure us of the grave nature 
of intussusception, and of the impotence of all ordinary methods of 



472 INTUSSUSCEPTION. 

treatment against it. In young infants, indeed, where the strength of 
the system cannot be expected to hold out until elimination occurs, in- 
tussusception is almost invariably fatal. In a single instance only has 
recovery by elimination been noticed so early as the end of the first 
year. In a few cases, where the symptoms were well developed and 
threatening, they have subsided and the infant has recovered, appar- 
ently from spontaneous reduction of the invagination. 

We must not, however, forget that during the early stage of this af- 
fection th.e diagnosis is somewhat doubtful, since young children fre- 
quently present symptoms of obstructed and loaded intestine, such as 
a distended, hard abdomen, constant unnatural straining, with evident 
suffering, and yet are entirely relieved after the administration and 
operation of laxatives. 

A few cases of cure of undoubted intussusception, by means of infla- 
tion, have also been reported even at this early age; so that, when 
treatment is instituted soon after the appearance of the symptoms, the 
case is not absolutely hopeless. In older children, that is to say, above 
three years of age, the prognosis is much less unfavorable, since treat- 
ment offers a certain amount of hope, and there is always the prospect 
of the occurrence of elimination of the invaginated bowel, if the strength 
of the patient has been sustained during the first week. 

Even after elimination has taken place, however, the prognosis should 
still be somewhat guarded, as the slightest indiscretion in diet may, 
either by the development of flatulence or by the escape of irritating, 
undigested particles into the intestine, cause a rupture of the recently 
formed Cicatrix and speedy death. 

Diagnosis. — Intussusception has been, until recently, regarded by 
all authors as an affection of obscure and doubtful diagnosis. With 
the light, however, which has been thrown upon this subject by the 
labors of Clarke, Gorham, Smith, and especially Eilliet, the diagnosis 
in the great majority of cases can be made with precision. It is true, 
however, as conceded by Eilliet, that "very rarely in early infancy, 
more frequently than later, there are certain cases of invagination im- 
possible to distinguish from other forms of intestinal obstruction; and 
that at all periods of childhood the diagnosis presents many diflacul- 
ties." 

With what diseases, then, could we confound this affection, occur- 
ring, as we have seen, suddenly in perfect health; attended by obsti- 
nate, thougl? rarely fecal vomiting; by marked constipation, but with 
frequent bloody discharges; by paroxysmal abdominal pain and tenes- 
mus; by the presence of a tumor, generally in the left iliac region; by 
the protrusion of the invaginated bowel from the anus; and by pro- 
found prostration and disturbance of the nervous system. It is to be 
remembered, indeed, that this group of symptoms, so characteristic when 
viewed together, are rarely all present; and that with the exception of 
the vomiting, constipation, and bloody discharges, there is no single 
symptom which is not more frequently absent than present. There 



DIAGNOSIS. 473 

are. nevertheless, a sufficient number present in nearly every case to 
enable us to form a diagnosis. 

The diseases which may most readily be confounded with intussus- 
ception are. 1st, impaction of the intestine with hardened feeces; 2d, 
typhlitis or perityphlitis; 3d, cholera infantum; 4th, dysentery; 5th, 
intestinal hemorrhage; 6th, the various forms of internal strangula- 
tion; 7th, peritonitis. 

1st. AYhen an accumulation of fecal matter takes place in either the 
coecum or sigmoid flexure, the case may present many symptoms similar 
to those of intussusception. There is frequently such gastric and intes- 
tinal irritation, as to lead to occasional vomiting and paroxysmal ab- 
dominal pain; the bowels are constipated, and there is frequent and 
strong tenesmus, so as often to cause protrusion of the bowel. In addi- 
tion to these symptoms, a well-defined tumor is present in one or the 
other iliac fossa. 

These cases, however, often have presented symptoms of intestinal 
disturbance for some time previous to the attack; the vomiting is 
rarely so constant as in intussusception; the tumor is quite painless 
and has a peculiar doughy consistence; blood}^ discharges from the 
bowels are very rare; and we do not notice the profound prostration 
which exists in well-established invagination. During the early stage 
of the case, however, the diagnosis is doubtful; and when w^e have 
reason to suspect the presence of fecal accumulations, we must await 
the result of the administration of laxatives and laxative enemata, 
before deciding upon the nature of the case. 

2d. Inflammation of the coecum, appendix vermiformis, or of the 
pericoecal connective tissue, is attended with fulness or a well-defined 
tumor in the right iliac fossa, with vomiting, constipation^ and occa- 
sionally tenesmus, with distension of the abdomen and pain radiating 
from the right iliac region. 

There is, however, a marked degree of fever, and the symptoms of 
local peritonitis aj)pear early in the case ; the patient assumes a char- 
acteristic position, with the thighs flexed upon the pelvis, and the right 
iliac fossa is the seat of exquisite tenderness, so that the slightest pres- 
sure cannot be tolerated. The vomiting and constipation are not so 
marked and obstinate, and excepting in those cases which have been 
preceded by dysenteric symptoms, there are no bloody discharges, and 
as we have remarked above, the tumor or fulness is in the right iliac 
fossa ; whereas when this sign is present in intussusception, it usually 
occupies the left iliac region. 

3d. In cholera infantum, the vomiting is often incessant; the stools 
are frequent, with painful tenesmus; the abdominal pain paroxysmal, 
and occasionally the intestine protrudes from the anus. It is almost 
impossible, however, to mistake this affection for intussusception, if we 
remember that it is almost always accompanied by fever, with insatiate 
thirst, and prompt and extreme emaciation ; that the abdomen is with- 
out tumor, and rarely distended until towards the close of the case, 
and that the stools, instead of being bloody, are large and fluid. 



474 INTUSSUSCEPTION. 

4th. Dysentery frequently offers a close resemblance to intussuscep- 
tion so far as the characters of the stools are concerned, as they are 
often small and bloody, or muco-sanguinolent. But we do not see in 
dysentery the sudden inception, the rapid progress, the obstinate vom- 
iting, the moist tongue and moderate thirst, which characterize intus- 
susception. 

5th. We have seen that occasionall}^ the amount of blood passed by 
stool in intussusception is very great, and constitutes a true intestinal 
hemorrhage ; thus in the case reported by Marwick,^ it amounted to a 
large teacupful of pure blood. 

Intestinal hemorrhage is a very rare occurrence during childhood, 
but has been noticed in children in connection with polypus of the 
rectum, especially by Mr. Bryant; in typhoid fever, or the hemorrhagic 
form of some others of the exanthemata, and in the course of purpura. 
The absence of the other symptoms of intussusception, however, and 
the presence of the local or general symptoms peculiar to these various 
conditions, will serve to render the diagnosis easy. 

6th. Other forms of internal strangulation, such as those produced 
by a diverticulum from the intestine compressing it, by the adhesion of 
the vermiform aj^pendix so as to constrict the bowel, or by a contrac- 
tion of the calibre of the bowel, produce symptoms so identical with 
those of intussusception in second infancy, when the affection more 
nearly resembles intestinal obstruction in the adult, as to render diag- 
nosis impossible. The presence of an abdominal tumor, the occurrence 
of bloody stools, or the protrusion of the constricted bowel from the 
anus, w^ould be the only diagnostic signs. 

7th. Peritonitis, when diffuse, presents a few symptoms in common 
with intussusception; as the vomiting, constipation, abdominal pain 
and tenderness; and when the inflammation of the peritoneum is local- 
ized, there is in addition a well-defined sensitive tumor, which soon ap- 
pears as the result of the inflammatory action. The diagnosis here 
rests upon the greater frequency of the vomiting in intussusception, the 
more obstinate constipation with bloody discharges from the bowels ; 
the paroxj^smal nature of the abdominal pain, with less tenderness; 
the less degree of fever, the moist tongue, slight thirst, quiet respira- 
tion, and onl}^ moderately accelerated pulse. 

Treatment. — There is no special plan of treatment for intussuscep- 
tion deserving the name of preventive, owing to our ignorance of any 
symptoms which can be definitely regarded as the precursors of the 
invagination. The fact^ however, that various derangements of diges- 
tion, such as pain upon going to stool, diarrhoea, or constipation alter- 
nating with diarrhoea, have been occasionally noticed to precede the 
attack, should be an additional motive to urge us to meet these symp- 
toms by the most assiduous attention to the hygiene of the child, and 
to the regulation of its alimentary functions. 

^ London Lancet, July, 1846. 



TREATMENT. 475 

The curative treatment may be divided into three classes : the medi- 
cal, mechanical, and surgical treatment. 

Medical. — Depletion is strongly contraindicated by the tender age of 
the patients, and by the necessity of preserving the vital powers; since 
elimination, which affords the principal chance of recovery, does not 
occur until after the eighth day. In order, however, to relieve the en- 
gorgement at the point of constriction, without reducing the strength 
of the patient, it is advisable to apply a few leeches or cups to the ab- 
domen, and preferably to the right iliac region, unless a tumor can be 
detected, when, of course, they should be applied over its seat. 

Furgatives were formerly strongly advocated by most authors ; the 
one most generally advised being quicksilver, which was given with a 
view of overcoming the obstruction by its great weight and fluidity. 
The use of this agent is now, however, universally reprobated. 

In regard to other and less mechanical purgatives, there is still some 
difference of opinion. 

During the early stage of the attack, before the symptoms of intus- 
susception are very positively developed, we siiould advise the admin- 
istration of a mild but thorough laxative, such as castor oil, in conjunc- 
tion with large laxative enemata. If, however, at the end of twenty-four 
or forty-eight hours, the administration of these remedies, aided by the 
local depletion, has failed to produce an evacuation from the upper 
bowel, these measures should be abandoned, and recourse be had to 
means of calming pain and nervous disturbance, and to the sustentation 
of our patient. Among the remedies best calculated to allay the pain^, 
the tenesmus and the nervous irritability are : opium, in doses propor- 
tionate to the intensity of the pain; warm anodyne poultices applied 
to the abdomen, and warm baths carefully given. These latter are 
especially serviceable when the symptoms of nervous disturbance are 
marked, even amounting, as they occasionally do, to general convulsions. 

In endeavoring to sustain the child's strength, attention must be paid 
to the vomiting, which is generally so severe as to prevent any nour- 
ishment beino; retained. The remedies of most service asrainst this are 
counter-irritants to the epigastrium, opium, hydrocyanic acid, carbo- 
nated water, small pieces of ice kept constantly in the mouth or swal- 
lowed whole. 

Nutritious enemata may also be tried, but are rarely retained. 

The mechanical treatment consists in the injection of fluids or air into 
the bowel in such quantities as to distend it; and in the introduction of 
a large sound, with the view of pushing up the invaginated portion of 
intestine. The fluids generally used have been either tepid water or 
warm gruel, injected forcibly into the bowel, until the sudden cessation 
of resistance informs us of the reduction of the intestine. We have 
already seen that the seat of intussusception in the child is almost in- 
variably the lower end of the ileum, which passes into the coecum and 
is there constricted ; and, when we reflect that it has been frequently 
demonstrated that if fluid be forcibly injected into the large bowel, the 
ileo-coecal valve will rupture before any fluid is allowed to pass into 



476 INTUSSUSCEPTION. 

the ileum, it is evident that we can in this way exert a most powerful 
pressure upon the invaginated intestine. Experience shows that this 
procedure is frequently successful, even in cases where all medicinal 
treatment has proved unavailing; and there are now a sufficient number 
of such cases on record to render a resort to it proper. 

Air, however, both on account of its greater elasticity and mobility, 
as well as the greater facility of its introduction in sufficient quantity, 
is to be even more highly recommended. Indeed, inflation was advised 
by Hippocrates as a remedy in intussusception, but until within the 
past forty years does not seem to have been much practised. Two cases 
of obstruction of the bowels, occurring in adults, successfully treated 
by inflation, are reported in the American Journal of Medical Sciences^ 
for 1833: one by Dr. Janeway, of New York; the other, which, how- 
ever, was transcribed from the G-lasgoiv Medical Journal, for 1831, by 
Dr. King. The following year, in the Boston Medical and Stirgical Jour- 
nal, December 15th, 1834, Dr. J, Wood published a case, also in an 
adult, where death seemed imminent, but where the obstruction was 
readily overcome by inflation, and the patient recovered. Since then, 
this remedy has been frequently employed in intussusception in chil- 
dren, and with such good results, that it may fairly be said that the 
prognosis of this affection is less grave since the introduction of this 
remedial measure. To obtain the best results, inflation should be em- 
ployed early in the case, before any considerable amount of adhesive 
inflammation has taken place between the sheath and the contained 
intestine. The air is readily introduced b}^ a pair of ordinary bellows; 
the nozzle being inserted well into the rectum, and inflation continued 
until the obstruction yields. The return of the invaginated intestine 
is sometimes attended by a clearly audible sound, a species of crack, 
but it never gives any pain, and has generally seemed to afford relief. 
The complete restoration of the calibre of the intestine is proved by the 
copious feculent stools which frequently come away soon after the in- 
flation. 

A third mechanical means for restoring the displaced intestine has 
been recommended by Dr. Nissen, and consists in pushing up the in- 
vaginated portion by means of an oesophageal sound protected by a 
sponge. This proceeding would probably be readily accomplished, if 
the intussusception occurred far down in the large intestine ; but it 
would appear very difficult to replace in this way an invagination as 
high up as the ileo-ccecal valve. Dr. Nissen, however (in the Journal 
de Constatt, quoted by Eilliet and Barthez), gives two cases in which 
he succeeded in pushing up the intestine into the ascending colon, with 
complete relief of the symptoms of obstruction. There are also a few 
other cases of cure, by this means, upon record in medical literature. 

The surgical treatment consists in the performance of the operation 
of gastrotomy, finding the invaginated portion of bowel and reducing 
it by gentle traction. Opinions differ greatly as to the propriety of this 
operation in intussusception. The majority of authors, especially the 
English and American ones, however, seem to condemn it. They base 
their unfavorable opinion upon the grounds of the great difficulty of as- 



TREATMENT. 477 

certaining the exact position of the intussusception ; the difficult}^ of 
restoring the invaginated intestine even if found; and finally upon the 
dangers of the operation. 

We have seen, however, that in the majority of cases the invaginated 
mass will be found in the neighborhood of the left iliac fossa ; the lower 
end of the ileum having traversed the coecum, ascending and transverse 
colon, and these parts being successively inverted ; that in a certain 
proportion of cases a tumor is readily detectable ; and further, that some 
idea as to the seat of obstruction may be obtained from the distance to 
which enemata appear to penetrate. So that in a considerable propor- 
tion of the cases, we have the means of localizing the point of constric- 
tion, with a certain amount of definiteness. 

In regard to the difficulty of reducing the invaginated parts, authors 
differ greatly. It has been remarked, that even if the equivocal and 
uncertain nature of the symptoms of volvulus were not sufficient to 
deter us from undertaking the operation, the state of the invaginated 
parts would entirely banish all thoughts of such an imprudent attempt; 
since the different folds of intestine become so agglutinated to each other 
that they can hardly be withdrawn, even after death. 

Eilliet and Barthez (loc. cit.), however, conclude from their anatomi- 
cal researches, that in the majority of cases the disengagement of the 
intestines is very easily accomplished; and accordingly they declare 
that, " after employing medical treatment during three or four days, 
and after having made several attempts at inflation, we should not hesi- 
tate to perform gastrotoray." 

The great danger of the operation is, of course, apparent, but should 
hardly be considered an objection, w^hen we consider the fatal nature of 
this affection. Nor have the results of operation been such as to de- 
stroy hope; for in addition to several successful operations previously 
recorded, the only 3 cases of the 57 collected by Haven, in which gas- 
trotomy was performed, terminated favorably. 

To sum up our remarks upon this subject : after having tried for two 
or three days the medical and mechanical means recommended, with- 
out success, we must forbear and decide whether to trust the case to 
nature, with the hope of elimination of the invaginated bowel occurring, 
or to resort lo gastrotomy. And in this decision, the circumstances of 
each case must be taken into account; for if the case has not yet pro- 
gressed so far that adhesive inflammation has certainly taken place, and 
if we are able to detect the exact seat of constriction by the presence 
of a tumor, the operation certainly has strong arguments in its favor, 
and should not be hastily rejected. 

In those cases which have been trusted to nature, and when elimina- 
tion has fortunately occurred, we must treat the child, during this crisis, 
with the utmost care. The diet must be rigidly regulated, and the 
child kept in absolute repose. Nor must we relax these precautions 
for several weeks, and allow either indigestible food, or too large a meal 
of even the most digestible articles; since death has been several times 
known to follow this imprudence, from a rupture of the imperfectly 
formed cicatrix. 



CLASS IV. 

DISEASES OF THE NEE70US SYSTEM. 

GENERAL REMARKS. 

It is a very common opinion, both in and out of the medical profes- 
sion, that this class of diseases occasions a much larger number of 
deaths in childhood than any other. Indeed^ many persons suppose 
that, be the primary disease what it may, nearly all children who die, 
die, as it is said, by the brain. It appears, however, from an examina- 
tion of the bills of mortality for this city, that this opinion is not well 
founded. During the five years from 1844 to 1848 inclusive, the num- 
ber of deaths from diseases of the nervous system was less than from 
diseases of the digestive system, and though larger than those from 
diseases of the resj^iratory organs, not so much so as the popular 
notion would seem to warrant. The number of deaths from diseases 
of the nervous system was 3970; from diseases of the digestive system, 
4204; and from affections of the respiratory system, 3376. M. Barrier, 
whose observations were made at the Children's Hospital in Paris, says 
{loc. cit., t. i, p. 35) that, setting aside cases in which the nervous s^'mp- 
toms were probably only sympathetic of some other coincident dis- 
ease, the cerebro-spinal aifections were few in number in comparison 
with those of the thorax, abdomen, and senses, including amongst the 
latter the eruptive fevers. He states (loc. cit.] p. 34) that affections of 
the thorax constituted two-fifths of all the cases of disease, those of the 
abdomen and senses each one-fifth, and of the nervous centres only a 
tenth. M. Barrier, after combating the opinion so generally enter- 
tained, that disorders of the nervous system cause the death of the 
greater part of the subjects who die before puberty, says (loc. cit., t. ii, 
p. 233) that there is only one circumstance that in part justifies this 
opinion, which he opposes " not as false, but as exaggerated," and this 
is, that the affections alluded to are almost always of a dangerous 
character, that they are beyond the resources of art, and that they 
furnish a very considerable relative mortality. He says that, accord- 
ing to his experience, the mortality in diseases of the cerebro-spinal 
system has been as sixty-eight in a hundred, while in those of the 
thorax, senses (including the skin), and abdomen, it was respectively 
as forty-eight, forty, and thirty-two in a hundred. 

Before beginning the consideration of the particular disease's of this 
class, we are desirous of stating that we shall be compelled, on account 
of our limited space, to devote attention chiefly to those which are most 
important from their frequency or severity, avoiding or merely allud- 



TUBERCULAR MENINGITIS. 479 

ing to those which are of less consequence, or which occur in childhood 
merely in common with adult life. 

In our earlier editions we divided this subject into two classes, one 
containing all the diseases attended with and dependent upon, some 
appreciable alteration of the nervous centres, the second containing 
those in which no such alteration exists. We have since discarded 
that arrangement, principally on account of the minute researches of 
histologists during the past few years, which have all gone to prove 
the existence of positive and definite tissue-changes in many diseases 
previously regarded as purely functional. 



AETICLE I. 

TUBERCULAR MENINGITIS. 

Definition; Synonyms; Frequency. — This disease is characterized 
by violent cerebral symptoms, dependent upon the existence of tuber- 
cular granulations in the pia mater, as the essential anatomical lesion; 
accompanied, in the great majority of cases, by coincident inflammation 
of that membrane, by softening of the central parts of the brain, by ef- 
fusions of serum into the ventricles, and in many instances by tubercu- 
lar deposits in other organs. Formerly tubercular meningitis, simple 
acute meningitis independent of tuberculization, and simple dropsical 
effusion within the cavity of the cranium independent of inflammation, 
were confounded together under the single term of acute hydrocephalus 
or water on the brain. It has been shown, however, that a large ma- 
jority of the cases of acute hydrocephalus of authors are, in fact, cases 
of tubercular meningitis, and more recent researches have further shown 
that most of the remaining cases are in reality due to the altered con- 
dition of the blood, called uraemia, and are independent either of any 
material lesion of the brain or of the presence of an excess of serous fluid 
in its cavities. 

The term acute hydrocephalus ought to be therefore restricted to 
the single condition of sudden serous effusion in or around the brain, 
independent of any inflammation; a condition which only occurs in 
connection with the causes of general dropsy, and especially with renal 
disease, and is, indeed, merely the most rare form of internal dropsy, 
and, as such^ not to be regarded as a separate disease. A description 
of the symptoms of this condition will be found in our remarks upon 
the renal complication of scarlatina. 

There can be no doubt that tubercular meningitis is of rather fre- 
quent occurrence, though we are acquainted with no statistics except- 
ing those given by M. Barrier {loc. cit., t. i, pp. 34, 36), which will enable 
» us to form anything like an accurate idea upon this point. That author 
states that during the period in which his observations were carried on 



480 TUBERCULAR MENINGITIS. 

at the Children's Hospital in Paris, there occurred 576 medical cases of 
all kinds. In this number there were only 10 eases of tubercular men- 
ingitis, whilst there were 83 of pneumonia, 48 of pleurisy, 24 of typhoid 
fever, 48 of measles, &e., &c., showing the first-named disease to be much 
less frequent than many other affections. We may also form some idea 
of its frequency in proportion to other diseases, by a reference to the 
work of MM. Eilliet and Barthez (lere edit.), who report 33 cases of 
tubercular meningitis, against somewhat over 245 of pneumonia, 174 
of bronchitis. 111 of typhoid fever, 167 of measles, and 87 of scarlet 
fever. We are of opinion that it is not of frequent occurrence amongst 
the easier classes of this city, since we have met with less than 50 cases 
in private practice in the course of thirty years. From what we have 
been told by other practitioners, however, it seems probable that it is 
much more common amongst the destitute classes, and particularly the 
blacks, who crowd the southern parts of the city, and who suffer to a 
great extent from tubercular and scrofulous diseases. It is, however, 
impossible to obtain accurate information in regard to the frequency 
of the disease in this city, in comparison with other affections of the 
brain, from a reference to the bills of mortalitj^, because of the fact that 
all or nearly all these affections are returned under the titles of dropsy 
and inflammation of the brain. 

Predisposing Causes. — MM, Eilliet and Barthez (2eme edit., t. iii, p. 
511) state that the disease is very rare in the first year of life ) that it 
becomes notably more frequent in the second year, but that it is be- 
tween two and seven years of age that it occurs with the greatest fre- 
quency. After this, it diminishes, they say, rapidly from eight to ten, 
and especially from eleven to fifteen years of age. The influence of sex 
has not been determined, but it appears probable that boys are some- 
what more subject to it than girls. It has been clearly shown by the 
observation of various writers that the disease usually attacks delicate 
children, and especially those born of parents who are either themselves 
laboring under tuberculosis, or in whose families that diathesis has ex- 
isted to a greater or less extent. Of the 31 cases that have come under 
our own observation in which we have preserved notes of the disease, 
in 20, one of the parents either had phthisis at the time, or died of it 
subsequently; in 3, one or the other parent came of a tuberculous family, 
though in these both parents were living at the time in seeming good 
health; in 4, no trace of tuberculosis could be found in the parents or 
in their families, and in 4 the history of the parents or of their families 
could not be traced out. It is not uncommon for several children in a 
family to die of tubercular meningitis. Under these circumstances, it has 
nearly always been ascertained that the parent's, or some of the imme- 
diate relations, have either died of tuberculous or scrofulous disease, or 
shown unequivocal signs of one of those diatheses. Thus, 4 of the above- 
mentioned 20 cases occurred in two families, in one of which the father 
is since dead of phthisis, and in the other the mother has long been 
ailing with inactive tubercle of the lungs, and slow caries of a bone, > 
in all probability of tuberculous origin. It may follow other diseases, 



ANATOMICAL LESIONS. 481 

and has been observed particular!}^ after measles and other fevers, and 
after the suppression of eruptions. 

M. Barrier (op. cit., t. ii, p, 379) explains, and we think with good 
show of reason, the causes of the disposition on the part of the tuber- 
cular diathesis in children to localize itself in the brain, as well as the 
disproportionate violence and extent of the inflamniator}^ action in com- 
parison with the degree of the tubercular lesion, by the physiological 
conditions of the nervous system in early life, which are those of great 
functional energy and nutritive activity. 

As to the exciting causes, nothing positive is known. . The disease has 
been supposed to be brought into action by falls and blows upon the 
head, by violent moral emotions, and by exposure to the sun. These 
causes, however, are all of doubtful influence. 

AxATOMiCAL Lesions. — The tubercles which constitute the essential 
anatomical element of the disease are very rarely found upon the free 
surface of the arachnoid, but almost invariably beneath that tissue, or 
in the meshes of the pia mater. They usually appear as more or less 
opaque gray granulations, the so-called miliary tubercles, and may gen- 
e;rally be seen through the arachnoid, scattered about in the shape of 
small, rounded, or flattened bodies, of grayish or yellowish-gray color, 
and varying in size from two-fifths to four-fifths of a line. When the 
finger is passed over the arachnoid above them, they may be usually 
felt as little granular bodies. Their size, however, varies very much, 
and they are in some cases so small and so closelj^ resemble in color 
the surrounding parts, that it requires a careful search to detect them. 
They vary also greatly in number, being in some cases thickly scattered 
over a considerable extent of the pia mater, while in other cases but 
two or three can be discovered on each hemisphere. 

Frequently they can be detected with most ease upon the processes 
of pia mater which dip down between the convolutions, so that if we 
fail to find any granulations upon the surface, we should always strip 
off the pia mater and carefull}'- examine these processes. Upon a care- 
ful examination of the arrangement of the miliary tubercles, it will 
often be observed that they are clustered about the small arterioles of 
the pia mater, and evidently follow in their distribution the branches 
of these vessels. 

These granulations are not found upon all portions of the brain 
equally in cases of tubercular meningitis. On the contrary, they are 
rarely present upon its convexity or lateral aspects, while they are uni- 
formly present at the base, and especially about the optic chiasm and 
the fissures of Sylvius. 

Upon microscopic exa)nination of one of these granulations, its tissue 
is seen to be composed of numerous oval cells, with a single nucleus, 
though there are also some larger cells mixed with these which contain 
several nuclei. In many instances, as has been observed by Cornil,^ 

1 Arch, de Phys. Norm, et Path., 1868, p. 98. 
31 



482 TUBERCULAR MENINGITIS. 

Hayem/ Bastian,^ and ourselves,^ the tuberculous granulation will be 
seen to envelop a small arteriole, whose calibre is obstructed at the 
point of its development. There is also marked proliferation of the 
cells of the peri-vascular sheath of the vessel for a varying distance on 
either side of the granulation, and it is highly probable that it is from 
these cells that the granulation has been developed. 

We think it probable that some of the granulations may also be de- 
veloped from the cells of the connective tissue, which holds together 
the vessels of the pia mater. 

These miliary tubercles precede the occurrence of the inflammatory 
changes in the meninges described below, and sometimes it happens^ in 
very acute cases, that the only lesions discoverable consist of a few 
gray granulations scattered in the meshes of the pia mater. It is not 
probable, however, that they exist any great length of time without 
giving rise to meningitis, since they are usually found associated with 
more or less abundant inflammatory exudation, which surrounds and 
often conceals them. The chief seat of this inflammation, as of the 
tubercular deposition, is the pia mater ; the arachnoid membrane being, 
as a general rule, afl'ected only to a slight extent. That membrane 
sometimes, however, contains a very small quantity of clear or turbid 
serum in its cavity. Its surface is often dry and viscid, and in some 
instances its whole tissue is opaque and thickened. But it is chiefly 
in the pia mater that are found the evidences of severe inflammation. 
In order to detect these changes, it is necessary to examine the mem- 
brane not merely upon the surface of the brain, but to tear it off", so as 
to bring into view the portions w^hich dip in between the convolutions, 
and which often exhibit the greatest amount of morbid alteration. The 
inflammatory lesions vary between mere vascular injection, infiltration 
with clear, turbid, or gelatinous liquid, and abundant formation of 
lymph. When the inflammation has gone bej^ond mere sanguine injec- 
tion, it is marked by infiltration of the membrane with turbid, whit- 
ish, or sanguinolent serum, with pus, or with whitish or yellovvish 
lymph. These products are, like the tubercular granulations which 
they imbed and often conceal, most abundant at the base of the brain, 
about the peduncles of the cerebrum, the optic chiasm, and in the fis- 
sures of Sylvius. In this respect the disease difl'ers from simple men- 
ingitis, in which the results of inflammation are usually more abundant 
and well marked upon the convexity than at the base. The pia mater, 
which, in a healthy brain, can be readily detached from the surface of 
that organ, becomes, in cases of meningitis, particularly in those which 
are violent, more or less adherent, so that in tearing it off" portions 
of the cineritious substance, which is itself softened, come with it. The 
proper tissue of the membrane is thickened and indurated, the degree 
of thickening depending on the amount of infiltration. 

1 Etudes sur les Diverses Formes d"Encephalite, Paris, 1869. 

2 Edin. Medical Journal, 1867, p. 875. 

3 Trans, of Biological and Micros. Section of Acad, of Nat. Sci. of Phila., 1869. 



ANATOMICAL LESIONS. 483 

After the changes in the pia mater, the most important anatomical 
feature is effusion within the ventricles. This was former!}- thought to 
be the essential lesion of the disease, but recent researches have shown 
that it is absent in some instances which have followed in all respects 
the ordinary course of the malady. According to M. Barrier, effusion 
cannot be supposed to exist unless the ventricles contain from one and 
a half to two ounces of fluid, whilst Rilliet and Barthez assert that the 
normal quantity is a few grammes (about a drachm). The quantity in 
this disease is very variable; sometimes there are only a few drops or 
a teaspoonful, while in other instances it amounts to three ounces and 
a half, or much more. It may be so large as greatl}^ to distend the 
ventricles, rupture the soft commissure of the thalami, and even the 
septum lucidum, diminish considerably the thickness of the hemi- 
spheres, and flatten the convolutions against each other. In such cases 
the effused fluid passes through the membrane of the ventricle and in- 
filtrates into and softens the substance of the brain, so that the latter 
becomes almost of the consistence of thick cream. The characters of 
the fluid vary in different cases. It is white, perfectly limpid and trans- 
parent, or may be turbid, either from being secreted in that condition 
or from holding in suspension albuminous or purulent flocculi, or por- 
tions of the broken-down walls of the cavity. In some rare instances 
it is sero-sanguiolent. Eilliet and Barthez remark that the effusion 
which coincides with tubercular meningitis is different from that which 
accompanies tubercles of the substance of the brain. In the former it 
takes place rapidly, is turbid, exists in smaller quantity, and consti- 
tutes the condition formerly called acute hydrocephalus. In the latter 
it is secreted slowly and in considerable quantity, dilates the walls of 
the cranium, and constitutes one form of chronic hydrocephalus. 

The brain itself presents various morbid alterations. The whole 
organ often seems enlarged, so that the dura mater appears distended, 
and when the latter is cut into, the cerebral substance protrudes in the 
form of a hernia. At the same time the convolutions are observed to 
be pressed against each other, and the anfractuosities seem to have dis- 
appeared. The compression of the brain depends either upon the dis- 
tending action of the ventricular effusion, or upon sanguine turgescence 
of the organ. In most cases, but not in all, there is evident congestion 
of the cerebral substance, shown by a more or less abundant dotted 
redness, and sometimes by a general rosy tint of the medullary, and 
vivid redness of the cortical portion. Softening of the substance of 
the brain is of common occurrence in connection with the other lesions. 
We have already spoken of the softening of the walls of the ventricles 
where there is much effusion, and which in some cases appears to result 
from the macerating influence of the fluid. In many other cases, how- 
ever, microscopic examination of the softened brain tissue shows the 
effects of inflammation in the. presence of numerous granule-cells, free 
granular matter, and a disintegrated condition of the nerve-fibrils. 
The lining membrane of the ventricles also presents abnormal appear- 
ances in a majority of cases. In some these consist merely in injection 



484 TUBERCULAR MENINGITIS. 

with loss of polish and transparency; in others, however, by viewing 
the surface sideways, we can detect a very finely granular condition, 
as though the membrane had been sprinkled with fine sand. Loschner 
(Aus dem Franz Joseph Kinder spit ale ^ I860, Prague), has found this ap- 
pearance to be due to a proliferation of the cells of the ependyma. the 
minute granulations consisting of rounded nucleated cells. In Dr. 
West's minute anal^^sis of 61 autopsies of tubercular meningitis, also, 
the lining membrane of the ventricles presented evidences of inflam- 
mation in a large proportion of the cases. We have also referred, very 
cursorilv, to the softening which exists under the inflamed portions of 
the membranes, and which occasions adhesion of the pia mater to the 
brain beneath. In the latter cases the softening may be either red or 
white, and does not penetrate more than a line, and often less, in depth. 

In addition to the changes already described, tubercles of the brain 
itself may be occasionally met with, having no connection with the 
meninges. These are found in various parts of the organ, and differ 
greatly in size, varying generally between that of a millet-seed and 
hazel-nut, but reaching sometimes the volume of a pigeon or hen's-egg, 
or even that of half the fist. 

We have but few words to say in regard to the lesions of other 
organs. It is undoubtedly true that in the vast majority of cases 
tubercles are found in other parts of the body. ^ Of all the cases of 
tubercular disease observed by Eilliet and Barthez, amounting to 312, 
in onl^^one w^as the deposit confined to the meninges (o^. cit., lere edit., 
t. iii, note, p. 49). M. Yalleix {op. cit., t. ix, p. 196, 197), states, that in 
all the cases, without exception, of tuberculosis of the meninges in adults, 
tubercles exist also in the lungs, and that the sameis true, in the vast 
majority of cases, in regard to children. The organs in which the de- 
posit is most apt to exist are the bronchial glands, lungs, mesenteric 
glands, pleura, and peritoneum. 

Another very frequent lesion is softening of the stomach. This may 
afl'ect only the mucous or all the coats, so that a slight degree of force 
will suffice to tear the organ. Dr. Gerhard (Am. Jour. Med. Sci., vol. 
xiv, 1831) states, that lesions of the stomach existed in six of the ten 
cases detailed by him, and in four-fifths of others not detailed. 
• Before quitting this subject, we would call the attention of the reader 
to the fact mentioned by M. Yalleix (op. cit., i. ix, p. 214) that all the 
83'mptoms about to be described as constituting the disease under con- 
sideration, with the exception of paralysis, may depend on simple 
tuberculosis of the meninges. Several cases have been cited, in fact, in 
which the only lesion found after death consisted of granulations in the 
pia mater. No traces of inflammation w-ere observed. It is clear, 
therefore, that the evidences of the disease, or symptoms, depend not 
merely on inflammation caused by the tubercular deposits, but on the 
presence of that morbid production. The paralysis, which is one of 
the important symptoms, is thought to depend chiefly on softening of 
the substance of the brain. The author referred to states that it occu- 
pies the side opposite that in which the change exists. 



SYMPTOMS. 485 

Symptoms; Course; Duration. — The disease has been divided by 
authors into different stages, founded on the predominance of certain 
symptoms at particular periods of its course. 

These divisions are all imperfect and unsatisfactory, because the dis- 
ease is in fact a continuous one. and for this reason some writers have 
avoided attempting any classification of the S3^mptoms. We can, how- 
ever, obtain a more faithful picture of the disorder by adopting the 
division made by M. Talleix, which, though arbitrary and imperfect, 
because of the want of a natural line of demarcation, seems warranted 
by the very great differences in the character of the symptoms at an 
early and late period of the affection. We shall therefore describe first 
the invasion of the malady, and then two stages or periods of the 
symptoms after the disease is confirmed.' 

The invasion of the disease may be either insidious or sudden. In a 
large majority of the cases, the onset is preceded by a well-marked 
prodromic period. The length of this period varies greatly in diA'ercnt 
subjects. Its duration is stated b}^ MM. Rilliet and Barthez to be, as a 
general rule, between fifteen days and three months, scarcely ever less, 
and rarely more. During this period, the symptoms presented by the 
child are those which are usually held to be indicative of a failure in 
the general health. The nutritive functions especially show disorder. 
The appetite diminishes, or becomes capricious, there are alternations 
of constipation and diarrhoea, the body grows thin, the color pales, the 
gayety of childhood disappears, and the patient becomes listless, apa- 
thetic, and complains of being tired and weak; or he is irritable and 
peevish, or too mild and gentle; study and exercise both become dis- 
tasteful, and there is a degree of weakness and debility which, though 
slight at first, becomes at length so evident as to arouse the attention 
of the parents, or those who have charge of the child. Besides these 
sym2')toms, there is often very great restlessness at night. The only 
pain complained of is headache, and sometimes abdominal pain. The 
headache is, in subjects old enough to notice and describe their sensa- 
tions, often a prominent symptom. It is not constant, but occurs at 
intervals, and is sometimes severe, and its returns frequent. Fever is 
not generally present until after the more positive symptoms have fairly 
begun, and when present is generally slight and fugacious. The ema- 
ciation and loss of strength are seldom present to such a degree, in the 
prodromic stage, as to confine the child to the house. On the contrary, 
he continues to amuse himself at times, and to walk as usual. 

The following is a rapid and summary account of the mode of inva- 
sion in some of the cases that have come under our own observation : 

In one case, in a girl six j^ears of age, the invasion was preceded 
during three months by occasional cough, and irregular attacks of 
fever, by progressive emaciation, paleness, languor alternating with 
extreme irritability, disinclination to take exercise, and during the 
latter part of the time by partial lameness, and in fact by all the signs 
of general tubercular disease. In another, which occurred in a boy 
eight years of age, it was preceded for several months b}^ frequent 
complaints of intense headache, especially after taking active exercise, 



486 TUBERCULAR MENINGITIS. 

and by unusual languor, but no other symptoms. The boy was sent to a 
boarding-school apparently" well, and was suddenly attacked there. 
In five cases the meningeal symptoms were developed in connection 
with those of phthisis, whilst in an eighth they followed a state of 
general weak health, with dyspeptic symptoms, which had lasted for 
several months. In a ninth case, a violent convulsion, seemingly de- 
pendent on a fit of indigestion, was followed during four months by 
irregular and diminished appetite, by some loss of strength and flesh, 
and by frequent attacks of severe headache, and at the end of that 
time, by the symptoms which denote inflamm.ation of the membranes. 
In a tenth, after some months of gradual thinning and general debilit}^, 
a convulsion occurred, also from indigestion apparently. This was 
recovered from, but a few days afterwards the symptoms of meningitis 
showed themselves, and followed their usual course. In an eleventh 
case, occurring in a girl ten years of age, there was a mild, almost con- 
tinuous fever, lasting four weeks, and resembling most closely typhoid 
fever, except that there was no diarrhoea and only a very few doubtful 
rose spots, when severe frontal headache, vomiting, slow and intermit- 
tent pulse, with drowsiness, declared the invasion of tubercular men- 
ingitis. In a twelfth, a girl three years old, born of healthy living 
parents, presented for four days the signs of gastric catarrh, with, how- 
ever, unusual irritability of temper alternating with a suspicious quiet. 
On the fifth day, there was just perceptible strabismus, after which 
the case went on in the usual way to a fatal result. In a thirteenth, 
in a girl five 3'ears old, of healthy living parents, but with tuberculous 
grandparents on the father's side, the general health failed slowl}^, 
with loss of appetite and flesh for one month. Then there set in lassi- 
tude, desire to lie about, with the most petulant irritability on the 
slightest disturbance, occasional vomiting, constipation, loathing of 
food, and gradual conversion of drowsiness into coma, and so on to the 
end. In the remaining cases that we have seen, the invasion was pre- 
ceded by much less decided prodromic symptoms. 

After the different phenomena above described as characteristic of 
the prodromic stage have continued during a variable length of time, 
the disease enters into activit}", a change which is ushered in by three 
important symptoms: headache, vomiti7ig, and constipation, to which is 
added, in a large majority of the cases, slight acceleration of the circula- 
tion. At the same time the intelligence remains perfect, the strength is 
not greatly diminished, the appetite is not entirely lost, and the thirst is 
moderate. 

First stage. — The headache, vomiting, and constipation persist and 
become more marked. Headache is a nearly invariable symptom in 
children old enough to describe their sensations, and is therefore very 
important. In infants its presence is to be inferred when the child 
carries its hands frequentl}^ to various parts of the head, and presses 
strongly against it, and when the head is constantly rolled from side to 
side. It is generally frontal, and is usually referred to a point just 
over one or both brows. In other cases it extends over the whole 
head. It is commonlj^ severe, so that the child when old enough com- 



SYMPTOMS OF THE FIRST STAGE. 487 

plains of it spontaneously. In the case of a girl seven years old, whom 
we saw, it was so severe that she cried frequently and bitterly, begged 
to have the doctor sent for, and eubniitted willingly to any remedy 
siio-o-ested with a view to its relief. It is thousrht that the acute, shrill 
cry of the disease, to which the term hydrencephalic has been applied, 
depends on the acuteness of this pain. It usually lasts throughout the 
first stage, and ceases only as the delii-ium and coma of the second 
stage come on. Vomiting is also a nearly constant symptom. Of 80 
cases collected from different sources by M. Barrier, it was absent only 
in 15, or less than a fifth. This symptom generally makes its appear- 
ance on the first day, rareU' later than the second or third, and lasts 
two or three days, and sometimes longer. In one case that we saw, it 
lasted eleven days, though it was but slight on the tenth and eleventh. 
The matters ejected from the stomach consist of the ingesta, and of mucus 
and bile in various proportions. It is commonly repeated two or three 
times a day. Constipation is even more important as a symptom than 
the one last named. Of 87 cases it was absent only in 7, according to 
Barrier. MM. Eilliet and Barthez state, however, that it exists at the 
beginning only in about three-fourths of the cases. Where there is 
diarrhoea instead of constipation, at the invasion, as sometimes happens, 
the former symptom almost always depends on tubercular disease of 
the intestine. Even under these circumstances, however, the diarrhoea 
is sometimes arrested, and constipation substituted under the influence 
of the cerebral disease. The constipation generally persists obstinately 
for several days, and then gives way under the influence of purgative 
medication, or is replaced spontaneously by diarrhoea with involuntary 
stools towards the termination of the case. 

In connection with the three important symptoms just described, 
there are others, which, though less characteristic, are of much assist- 
ance in forming the diagnosis. The child is dull and sad, or excited and 
irritable by turns; he shuns the light, or closes the eyelids and contracts 
the brows when it is thrown upon the face; his hearing becomes pain- 
fully acute, so that sudden and jarring sounds distress and irritate him ; 
the sleep is restless and disturbed, and accompanied by grinding of the 
teeth ; and he utters from time to time, both sleeping and waking, the 
peculiar shrill, sharp, and sudden scream, which seems to depend upon 
internal pain, probably headache, and which has been called by Coin- 
det the hydrencephalic cry. In young children, those who have not yet 
learned to put their sensations into words, a peculiar, apparently cause- 
less, obstinate peevishness and positive ill-temper, shown by sudden, 
sharp crying at any disturbance, as even the kindness of a father or 
mother, especially when this alternates with sluggishness or drowsi- 
ness, and when there is no evident disease of a painful or exhausting 
kind to explain such a state, ought to arouse the fears of the physician 
as to the possible inception of this disease, even when there is as jQt no 
vomiting or distinct signs of headache to call attention to the brain. 
The general as well as the special sensibility is sometimes but not l\y 
any means always, exaggerated at this time. Eilliet and Barthez met 
with exaltation of this function only in four of their patients. The 



488 TUBERCULAR MENINGITIS. 

intellectual faculties remain undisturbed in the majority of the cases 
duriniv the first few days, and this fact, which is so contrary to what 
miglit be expected, is one of the utmost importance in the judgment of 
the case. We remember being asked b}' a little girl seven years old, 
to whom we have already referred, " why it was that she saw double; 
why she saw two mothers and two doctors?" At the time when she 
first asked the question there was no perceptible strabismus, but on the 
following day we thought we could detect a deviation of one of the eyes 
from its proper axis, and on the third day the deviation was very 
marked, though the poor child still wondered why she saw two objects 
instead of one.^ In another case in a boy five years old, there was no 
disorder of the intelligence until the eleventh day, when there was 
slight delirium alternating with somnolence; yet it was clear from the 
first that the attack would prove one of tubercular meningitis, from the 
coexistence of violent frontal headache, obstinate vomiting, constipa- 
tion, slow and irregular pulse, and the absence of other local or general 
symptoms. In only a fifth of the cases observed by MM. Eilliet and 
Barthez was there perversion of the intellectual faculties at the inva- 
sion. Let us observe, moreover, that even when children present some 
of these disorders earlj^ in the attack, they generallj^ consist only of 
slight delirium, dulness of the intelligence, slowness and hesitation in 
answering questions, disposition to somnolence, excessive irritability 
and peevishness of temper, and what is more important and character- 
istic than any of these, perhaps, of a certain expression of the counte- 
uance, and particularly of the look, which is expressive of astonishment 
or of the utmost indifference. The look is, in fact, fixed or staring", 
like that of one in a mild ecstasy. Even when these symptoms exist, 
however, at an early period, they not unfrequently alternate with the 
most perfect clearness of the faculties, so that the physician in private 
practice, who sees his patient only at long intervals, and for a few mo- 
ments at a time, should never venture to disbelieve, without due con- 
sideration, the account of the mother or nurse as to their occasional 
presence during his absence, even though never observable during his 
visit. We knew this to happen in regard to two boys of eight and ten 

1 Use of the Ophthalmoscope in Tubercular Mekikgitis. — In this disease, 
as in acute simple meningitis, the obstruction to the return of venous blood through 
the sinuses produces in both eyes, but especiallj^ in the one corresponding to the 
hemisphere where the inflammation is most intense, congestion and oedema of the 
optic papilla and surrounding tissue (Bouchut's peripapillary congestion) ; tortuosi- 
ties and varicosities of the retinal veins ; and occasionally thrombosis or rupture of 
these vessels, causing minute hemorrhages in the retina. In some cases the size of 
the globe is increased, owing to hydrophthalmia. These lesions are indeed more 
frequent in this disease than in simple meningitis, since the inflammation and re- 
sulting exudation are more apt here to involve the base of the brain, and cause a 
greater degree of obstruction to the circulation. 

These retinal lesions cannot be regarded as pathognomonic of the existence of this 
disease, aud are therefore onl}'^ valuable as confirmatory of the general symptoms, 
save in certain cases where the development of the ocular lesions before the appear- 
ance of the more characteristic symptoms might enable the diagnosis to be made at 
an earlier date than would be possible without ophthalmoscopic examination. 



SYMPTOMS OF THE FIRST STAGE. 489 

years of age respectively, whose mothers constantly insisted to the 
physician in attendance that during his absence the children occasion- 
ally presented slight delirium, and a wild uncertain expression of the 
countenance, which made them fear that the brain might be affected. 
As the children's intelligence was perfect, however, whenever the doc- 
tor saw them, he determined that the mothers were fanciful through 
over-anxiet}', and ascribed the sickness to a bilious disorder of the 
stomach. After a few days the cases developed themselves, and the 
boys died with every symptom of tubercular disease of the brain. 

When disorders of intelligence do not occur in the earl}^ days of the 
attack, they usually make their appearance about or soon after the fifth 
day. 

Durino' the first stao-e the coloration of the face ouo;ht to be noticed. 
It is generally paler than natural, though from time to time a sudden 
flush of redness maybe seen to pass over it. The condition oi IhQ senses 
is natural, except that the acuteness of the eye, ear, and sometimes that 
of touch, are exalted, so that the child avoids the light, starts at sudden 
or loud sounds, and cries when it is touched or moved. The resjnra- 
tion becomes unequal and irregular, and is interrupted by sighing or 
yawning. 

Convulsions rarely occur in the first stage. MM. Eilliet and Barthez 
conclude that meningitis without complication of tuberculous disease 
of the cerebral substance, never begins with convulsions. In one of the 
cases that came under our charge, a severe and prolonged convulsive 
seizure did occur, however, on the very first day of the attack of the 
disease. The subject of the case was a boy between four and five years 
old. The death took place on the eighteenth day, and the autopsy 
showed no tubercular disease of the cerebral substance. It is proper 
to state, however, that the child had eaten on the morning of the day 
that he was attacked, a most unwholesome meal, and it is very possible, 
as we in fact supposed at the time, that the convulsions were caused 
by the presence in the stomach of undigested food. When they do 
occur in tubercular meningitis, they may be limited to the extremities, 
upper lip, eyeballs, or they may be general. Sometimes the child dies 
in a convulsion. They are generally much less important as a symp- 
tom, according to M. Yalleix, than in simple acute meningitis. 

The tongue remains moist; the appetite is not entirely lost; thirst is 
moderate; the constipation continues, unless removed by treatment; the 
abdomen becomes retracted, so that its walls approach closely to the 
spinal column, and allow us to feel the pulsations of the aorta without 
using more than very slight pressure. The latter symptom comes on 
gradually, and is generally well marked by the sixth day or a little 
later. MM. Eilliet and Barthez regard it as a very important sign, and 
state that they have observed it almost exclusively in cerebral afl:ections. 
They think it depends not upon contraction of the abdominal muscles, 
but upon retraction of the intestines. We can corroborate b}^ our own 
experience, the evidence of the above authorities as to the value of this 
symptom. It has been very marked in the cases that we have seen. 

The state of ih^ circulation is of the utmost importance in forming the 



490 TUBERCULAR MENINGITIS. 

diagnosis. So true indeed is this, that Dr. Whytt, of Edinburgh, whose 
description of acute hydrocephalus, published in 1768, has been most 
highly commended by all recent writers as a singular instance of accu- 
rate observation, makes three stages of the disease, each of which is 
characterized by the state of the pulse. In the early part of the attack 
the pulse is accelerated, rising to 110, 120, or, according to Whytt, in 
a few cases to 130 or even 140. At the same time it is neither full nor 
tense, as a general rule, but rather soft and compressible. This con- 
dition of the pulse changes, as we shall find, in the middle period of 
the disease, and again shortly before the fatal termination. The heat 
of the skin is usually moderate and sometimes quite natural, at this 
time, as might be supposed from the state of the circulation. Fre- 
quently the temperature will not during this period exceed 100^ to 
100.5° : though occasionally marked and rapid changes in it are ob- 
served. It is especially to be noted that the temperature does not follow 
the regular mode of development so characteristic of typhoid fever. 

Second stage. — This stage begins about the time the more marked 
nervous symptoms show themselves. The headache generally subsides 
or ceases at the beginning of this period and gives place to delirium. 
This occurs usually somewhere between the sixth and twelfth days. 
The delirium which occurs has been generally supposed to be always 
mild and calm. MM. Rilliet and Barthez state, however, that in one- 
third of their cases it was intense, and accompanied with cries, agita- 
tion, and frequent changes of position. In most of the cases, however, 
it is mild, and is manifested in older children by their muttering unin- 
telligible words, by inattention to what is going on around them, by 
an expression of wildness and astonishment, and by their giving hesi- 
tating answers to questions. In children under two years of age there 
is no proper delirium. There is, however, an analogous condition, 
which is characterized by disorder of the two faculties of attention and 
perception. The delirium seldom lasts more than two or three days, 
and generally alternates with somnolence, so that the child is either 
dozing and sleeping, talking in its sleep, or frequently waking with 
loud cries, and restlessness. The general seiisibilify, which may have 
been e"xaggerated in the early period of the disease, is diminished in the 
earlypart of the second stage, or about the seventh day, and completely 
abolished towards the end. The face in the second stage is almost 
always pale, or pale and flushed alternately. During this stage, and 
especiall}^ during the latter part of it, it is very common to see sudden 
alterations in the color of the face. Sometimes without any apparent 
cause, but more frequently from disturbances of any kind, as from pain, 
or from external influences acting upon the child, such as moving it, 
or the administration of food or medicine, the face becomes suffused of 
a more or less deep pinkish or scarlet tint, the color beginning faintly 
at first and gradually deepening and expanding until it covers the whole 
face and forehead, and then as gradually fading away. It is during this 
stage also that another symptom, which we have often noticed, and to 
which M. Trousseau has called attention, may usually be observed. M. 



SYMPTOMS OF THE SECOND STAGE. 491 

Trousseau refers to it as a red line or spot remaining upon the skin ot 
the forehead or abdomen when the finger has been drawn across it, and 
has given to it the name of " tache meningitique," or '' tache cerebraUy 
We had often remarked, before knowing that M. Trousseau had drawn 
attention to this phenomenon, that the slightest pressure with the finger 
on any part of the face or forehead, caused the appearance at the point 
of pressure, of a spot of a peculiar pink or rose color, which, like the 
flush above referred to, began faintly, became more or less deep in tint, 
remained a few moments, and then as gradually faded away. This is 
no doubt one of the diagnostic symptoms of the disease. We do not 
recollect to have seen it in any other disease, except once in a severe 
case of typhus fever in an adult, in whom it was exceedingly marked. 
In this disease we believe it may always or nearly always be detected. 
Occasionally contractions pass over the features, giving rise to grimaces, 
after which the countenance resumes its expression of indifference and 
stupor. The eyelids are generally only partially closed, and between 
them the globes of the eyes can be seen to oscillate and move in various 
directions, as though by some automatic force. 

As the case progresses, the nervous symptoms become more and more 
marked; somnolence gradually deepens into coma; the delirium be- 
comes less and less frequent; and the child no longer observes what is 
going on, nor answers questions. As the somnolence and coma increase, 
various lesions of motility make their appearance, consisting, in order 
of frequency, of paralysis, which is generally partial; contraction with 
rigidity of the limbs; stiffness of the muscles of the back of the neck, 
causing retraction of the head ; stiffness of the trunk; spasmodic closure 
of the jaws; carphologia; subsultus tendinum, and convulsions. The 
paralj'sis is almost alwa^^s partial and of very limited extent, affecting, 
for instance, the jaw, the orbicularis muscles of the eyelids, the levator 
of the upper eyelid, the tongue, or one side of the face. It is very rare 
to see one of the limbs paralyzed. Contraction with rigidity of the 
muscles is an important symptom, but is not always present. When it 
exists it generally appears at an advanced period of the attack, com- 
monly between the seventh and thirteenth days, and is usually partial. 
It may affect either the extremities, back of the neck, trunk, or inferior 
maxilla. It is seldom permanent, but after lasting one or two days, 
disappears, to reappear at a later period. The carphologia, subsultns, 
and chewing motion of the under jaw generally occur only a few days 
before death, and last but a few days. 

The decubitus, in the early part of the second s-tage, is generall}^ lat- 
eral, with the thigjis flexed upon the pelvis, the legs u2:>on the thighs, 
the arms applied against the thorax, the elbows bent, and the hands 
placed in front, the decubitus called by the French '^ en chien de fusil" 
or gun-hammer. At this time the child will still occasionally move its 
position with facility, showing that strength is not by any means en- 
tirelj^ lost. At a still later period the decubitus is dorsal. • In the latter 
part of the first and early part of the second stage, the pulse, which we 
have ascertained to be accelerated at the invasion, falls to the natural 
standard, or becomes slow, and at the same time irregular. From 110 



492 TUBERCULAR MENINGITIS. 

or 120, as it was, it now sinks to 90, 80, 60, or, as happened in one in- 
stance to M. Guersant, to 48 in the minute. Coincidently with this 
change it almost alwaj'S becomes irregular. The irregularity affects 
both its force and frequency, so that a strong pulsation may be followed 
by a feeble one, or the rh3'thm may be regularly or irregularly intermit- 
tent. The irregularit}' varies greatly at different periods of the day, 
or within short spaces of time, so that the pulse is found to be very 
slow at one moment and much more frequent the next. On this ac- 
count it is necessary to examine it on different occasions. Slowness 
and irregularity of the circulation are important as a means of diagno- 
sis, since it has very rarely been met with as a permanent condition, 
except in the tubcrculo-inflammatory affections of the brain and its ap- 
pendages. Towards the termination of the disease, generally speaking- 
two or three days before death, the pulse rises again in frequency, so 
that it counts at first 112 or 120, and gradually increases to 140, 160, or 
even 200 the day before, or that on which death takes place. Simulta- 
neously with this change it also becomes extremely feeble and small, 
and often ceases to be perceptible at the wrist on the last day. The 
heat of skin, which has fallen with the reduction in the frequency of the 
pulse, generally increases with its acceleration. This is not invariable, 
however, since in some cases the temperature remains but moderately 
elevated, about 101° or 102°, until death; and in others an algid condi- 
tion precedes death, in which the temperature falls as low as 79.4°. 
(Eeynolds's Syst. of Medicine, vol. ii, p. 379, art. Tuberc. Meningitis.) 
On the other hand, in some cases the temperature increases irregularly 
as the fatal result approaches, and may attain an extreme height. Thus 
Eoger (op. cit., p. o23) has observed on the day of death in an attack 
of tubercular meningitis, a temperature of 108.5° F. During the last 
few daj'S the surface is often covered with an abundant perspiration ; 
the tongue becomes dry; the teeth and gums are fuliginous; the ex- 
haustion increases; the respiration becomes stertorous, unequal, diffi- 
cult, and anxious, and at the very last attended with great dj^spnoea; 
and the urine and stools are discharged involuntarily. Death finally 
occurs in this condition, or is hastened by an attack of convulsions. In 
some cases it is most lingering. In one instance we expected the death 
of a young child in this disease every day for eight in succession. 

The duration of tubercular meningitis is exceedingly^ variable in dif- 
ferent cases. As a general rule it lasts between eleven and twenty 
days, though it may continue a considerably longer time. Eilliet and 
Barthez have never known death to occur before the seventh day. 

Diagnosis. — The diseases with which tuberculosis of the menino;es 
is most likely to be confounded are simple meningitis and typhoid 
fever. It might also be confounded, though this is much less probable, 
with the cerebral symptoms which complicate the exanthemata and 
some local diseases, especiallj^ pneumonia, and to which symptoms, as 
a group, M. Barrier has applied the term pseudo-meningitis. 

The diagnosis between tubercular and simple meningitis will be best 
understood from the following synoptical table, extracted from the last 
edition of the work of MM. Eilliet and Barthez. 



DIAGNOSIS. 



493 



SIMPLE ACUTE MEXINGITIS. 

I. The subjects of acute simple menin- 
gitis are usually robust and well-devel- 
oped, and present no trace of either in- 
ternal or external tubercular disease. 
Born of healthy parents. 



II. The disease may prevail epidemi- 
cally. 

III. Condition prior to invasion. — The 
disease begins in the midst of the most 
blooming health, or, if secondary, it oc- 
curs in the course of, or during the con- 
valescence from, some acute non-tubercu- 
lar disease, or it follows an external cause. 

IV. Mode of invasion. — Violent con- 
vulsions attended with intense febrile 
movement, and with very hurried respi- 
ration in young infants; or very acute 
frontal headache, accompanied by fever, 
bilious vomiting, and towards the end of 
the first, or in the course of the second 
day, at the latest, excessive restlessness, 
preceded or not by somnolence ; most vio- 
lent delirium : formidable ataxia. 



V. Symptoms. — Fery intense headache, 
obstinate \on\\tm^^ moderate constipation, 
violent fever, higlt delirium. 

VI. From the beginning, the aspect of 
a grave disease of ataxic form, 

VII. Course rapid, aggravation pro- 
gressive and continuous ; convulsion after 
convulsion, or else violent delirium, ex- 
treme agitation, violent fever, &c. 

Duration. — Disease of short duration, 
ending sometimes in 24 or 36 hours, but 
lasting generally from three to six days, 
and seldom more. 



REGULAR TUBERCULAR MENINGITIS. 

I. Subjects of tubercular meningitis 
delicate, puny, exhibiting often precoci- 
ous intelligence and sensibility. Have 
sometimes had, in infancy, enlarged 
glands or chronic cutaneous eruptions ; 
the parents, or brothers and sisters, often 
present the signs of tubercular disease. 

II. Disease always sporadic. 

III. Co)idition prior to invasion. — For 
some months or weeks the patients grow 
languid, lose their strength, become pale, 
emaciate; their temper changes, they 
are dull, they lose appetite, the digestion 
is deranged, &c. Absence of prodromic 
symptoms is rare. 

IV. Mode of invasion. — Never with 
convulsions at the onset; the change 
from the prodromic to the acute stage 
sometimes imperceptible. It takes place 
by a progressive increase of the sjMiiptoms 
before mentioned, and by the setting in 
of headache ; in other cases, the acute 
stage is better marked by headache, vom- 
iting, and constipation ; generally, the 
intoUigenee remains clear ; no ataxia. 
In the rare cases in which there is ataxia 
at the onset of the acute symptoms, the 
prodromic stage, above described, has 
been observable, or the meningitis has 
occurred in the course of advanced phthi- 
sis. In cases in which no prodromes 
exist, the meningitis begins with vom- 
iting, constipation, moderate headache, 
and slight febrile movement ; ataxia, if it 
is to appear, occurs later, and a mistake 
is impossible. 

V. Symptoms. — Not very intense head- 
ache, vomiting less frequent^ very obstinate 
constipation, very moderate fever, slow- 
ness and irregularity of the pulse, delirium 
usually mild. 

VI. Invasion insidious, wnth the aspect 
of a mild disease. 

VII. Course slow, preservation of the 
intelligence to an advanced period, fever 
slight, and some slowness and irregularity 
of the pulse, sighing, changing color of 
the face, eye dull or ecstatic, &c. 

Duration. — Always much longer in the 
regular form. 



494 TUBERCULAR MENINGITIS. 

We will remark in regard to this table, which is, in most respects, 
admirable, that we have never met with more intense and persistent 
headache than Ave have in some cases of the disease under considera- 
tion. In some of our cases this has been a most prominent and strik- 
ing symptom. 

Before quitting the subject of the diagnosis of these two affections, 
it is desirable to state for the information of the reader, that some of 
the highest authorities acknowledge it to be sometimes nearly or quite 
impossible to distinguish between them. This is the expressed opinion 
of MM. Guersant, Kufz, Barrier, and Yalleix. 

From typhoid fever, tubercular meningitis is to be distinguished by 
the antecedent history of the patient, which often reveals the existence 
of a tubercular diathesis in the latter affection ; by the symptoms of the 
invasion, which in meningitis consist of severe and persistent headache, 
frequent vomiting, and constipation, whilst in typhoid fever the head- 
ache is less severe and less persistent, the vomiting much less frequent, 
and the constipation replaced by diarrhoea; by the different characters 
of the febrile movement, which, in typhoid fever, is more marked, and 
attended with a frequent, full, and regular pulse, while in meningitis it 
is less marked and is accompanied after a few days 'by slowness and 
irregularity of the pulse ; lastly, in meningitis, the constipation is ob- 
stinate, the abdomen retracted, and there are various important and 
characteristic lesions of motility, and the special senses; in typhoid 
fever there is diarrhoea, the abdomen is distended and meteoric, there 
are characteristic rose-colored spots, whilst there are no considerable 
lesions, either of motility, or of the special senses. Much assistance in 
the diagnosis can also be obtained by a careful study of the course and 
changes of the temperature in the two diseases. In tubercular menin- 
gitis, instead of the gradual progress in development, with moderate 
evening exacerbations, which is so characteristic of typhoid fever, the 
temperature presents great and irregular variations; it is specially 
marked by a period of reduction, even to 97° or 96° (Roger), corre- 
sponding to the middle stage, and then by a final rise, which may con- 
tinue increasing until the last day of life, or may be replaced by an 
algid state, with great lowering of the heat of the surface. 

In one of our cases we made this mistake. And yet, on looking back 
at the case, we could see that the very moderate heat of skin, the 
absence of diarrhoea and of epistaxis, and the imperfect development of 
the eruption, which consisted only of a few faint rose spots on the ab- 
domen, ought to have led us to suspect that the fever was of the tuber- 
culous, and not of the t3^phoid form. 

It is unnecessary to do more than allude to the possibility of con- 
founding the disease with the exanthemata, or with local diseases ac- 
companied by cerebral symptoms, and particularly with pneumonia in 
very young children. The resemblance of pneumonia of the apex of 
the lung in the early stage to tubercular meningitis, has been referred 
to in the article on pneumonia. The diagnosis must be made by care- 
ful consideration of the symptoms peculiar to each, and in the case of 



PROGNOSIS. 495 

a local disease, by accurate j^hysical examination of all the important 
organs of the body. 

Prognosis. — M. Barrier, in speaking of the prognosis of this affection, 
says: '-The gravity of tubercular meningitis is not surpassed by that 
of any other disease. Thoracic and abdominal phthisis, though almost 
constantly fatal, pursue a slower course, and last a longer time. We 
may even allow as proved, that in a small number of cases, they are 
susceptible of cure, or may remain stationary for months or years. 
Unfortunately it is not so in regard to tubercular meningitis." MM. 
Eilliet and Barthez, in their second edition, do not express the same 
entire hopelessness as to recovery from the disease, that they did in 
their first. They say, amongst other conclusions (op. cit., t. iii, p. 510), 
that there are on record incontestable examples of the complete dis- 
appearance of the symptoms, but remark, that such cures have oc- 
curred in the first stage, or in the first half of the second stage, after 
seven or eight days of sickness, rarely later, and after alternations of 
amelioration and aggravation. They state also that, in excessively rare 
instances, a return to health has been obtained even in the course of 
the third stage, after many weeks of illness. They are of opinion that 
the disease often returns and proves fatal in from one to five years and 
a half after the recovery. The cause of the relapse is to be found in 
the fact that the local lesion remains, and that the diathesis has not 
been eradicated. M. Yalleix is of opinion that after having acquired 
the conviction that a case is really one of tuberculosis of the meninges, 
we should regard the patient as lost; "for the exception that I have 
mentioned (a case belonging to M. Rilliet, then unpublished), even did 
no doubt as to ttie exactness of the diagnosis remain, ought not, stand- 
ing by itself, to impart to us any real security." M. Guersant (Diet, de 
Med. t. xix, p. 403), seems to think it possible that the disease may 
sometimes terminate favorably in the very early stage, but adds that 
" such cases are always more or less doubtful, and seem to us to belong 
rather, for the most part, to simple meningitis." During the second 
period (that of slowness and irregularity of the pulse), he has scarcely 
seen one child in a hundred survive, and even then they perished at a 
later period of the disease, or of phthisis pulmonalis. Of those arrived 
at the third stage (marked by renewed frequency of the pulse, coma, 
and lesions of motility and sensibility), he has never seen any recovery, 
even momentarily. Dr. George B. Wood (Prac. of Med., vol. ii, p. 365), 
states that he has " never seen a well-marked case of tuberculous men- 
ingitis end favorably." 

We shall quote but one more authority as to the prognosis of the 
disease. Dr. Eobert Whytt ( Works of Robert Whytf, published by his son, 
quarto, Edinburgh, 1768, p. 745), says : " I freely own, that I have 
never been so lucky as to cure one patient who had those symptoms 
which with certainty denote this disease ; and I suspect that those who 
imagine they have been more successful have mistaken another dis- 
temper for this." Our own experience coincides with the mass of evi- 
dence given above as to the almost hopeless fatality of the disease. All 



496 TUBERCULAR MENINGITIS. 

the undoubted cases that we have seen have proved fatal. A case, how- 
ever, came under our observation, in 1850, which might, perhaps, be 
classed as a recovery from tuberculosis of the meninges, though not 
from tubercular meningitis, since there were no well-marked signs of in- 
flammation of the membranes of the brain, though there was every reason 
to suppose that the symptoms depended on the deposit of tubercles in 
those membranes. The case was as follows : 

A girl between four and five jeRvs old, whose mother was then laboring under 
tubercular disease of the summit of one lung (which has since proved fatal), and who 
had lost several brothers and sisters with consumption, had had nearly constant 
cough during the winter of 1849-50. During the months of April, May, and June, 
of 1850, she had exhibited all the signs of induration over the upper two or three 
inches of the right lung, before and behind, — marked dulness on percussion and 
bronchial respiration, but no rale. For these symptoms she had been treated with 
cod-liver oil, iodide of iron, opium for the cough, and good diet. From the middle 
of June she complained frequently of headache, had occasional vomiting without 
any gastric derangement, and was much disposed to be constipated. She hud no ap- 
petite, grew thin, and was very languid, listless, and weak. On the 27th of June 
the mother thought she observed some squinting. On the 29th we found that the 
child had lost all power over the right muscles of the right eye, so that when she 
looked towards the right hand, she squinted dreadfully. She was dull and heavy, 
and vomited two or three times a day. The pulse was 62 to 75 or 80 ; there was a 
slight hitch in its beat, but no decided intermittence. The child said that she some- 
times saw two things instead of one. From this time until July 7th, she continued 
in much the same state. On the 1st July, finding that the eyes were quite yellow, 
and that the child was constipated, we ordered half a grain of calomel morning and 
evening. After three doses she was purged. This relieved her a good deal, there 
being less headache, more appetite, and an improvement in color afterwards. But 
still there was every day some vomiting, complaints of headache, and more or less 
listlessness and heaviness in the morning, while in the afternoon she would brighten 
up and seem better. The intelligence continued perfect ; the temper was rather 
irritable, but not very much so. 

The treatment after the 29th of June was calomel, given as above stated, from 
time to time, to keep the bowels soluble; cod-liver oil, a teaspoonful twice or three 
times a day, as the child would take it ; mustard foot-baths every day or two ; and 
meat, bread, and ice cream for diet. On the 5th July we ordered half a grain of 
iodide of potassium, three times a day, in addition to the oil. 

On the 11th July, she was taken, by our direction, to the seaside, where the use of 
the oil and of the iodide of potassium was to be continued. 

On the 7th of August she was brought back from the seaside, and we saw her on 
the 8th. AVe were astonished to see how well she looked. The strabismus had 
entirely disappeared. We were told that it had begun to diminish two weeks after 
her arrival at the sea, and had then gradually disappeared. She had grown some- 
what, though not very much, fatter. Her whole appeai'ance was very much im- 
proved. The coloration of the body, the expression of the face, were both much 
better; she was much stronger, running about, in fact, all day; she ate well, and 
with the exception of a little cough, and a rather delicate frame, looked very well. 
Except one day, she was well all the time at the seashore. On that day she was 
feverish, had much headache and vomiting, and laid abed. The cod-liver oil and 
iodide of potassium were ordered to be continued. 

The child remained pretty well throughout the winter of 1850-51. There was no 
return of either the strabismus or the vomiting. She was thin, pale, and delicate- 
looking, coughed occasionally, and the solidification of the summit of the lung con- 
tinued, but she was not confined to the house. Late in the winter she went south 



PROGNOSIS. 497 

with her mother, and there, after having hecome quite stout and healthy during 
their travels, died of dysentery in April or May. The mother died in 1852, of 
phthisis, with large cavities in hoth lungs. 

Another case, in which the early symptoms of the disease were well marked, and in 
which recovery took place, will be detailed in the remarks on prophylactic treatment. 

We have seen but two other cases which gave us the least reason for 
hope, after we bad once supposed the children attacked with the dis- 
ease. One occurred in a boy eight years old, who had been suffering 
for two weeks before we saw him with violent frontal headache, fre- 
quent vomiting, constipation, slight fever^ and somnolence. We fully 
expected that this would prove to be an attack of tubercular menin- 
gitis. A large dose of calomel followed by castor oil, and free leeching 
to the temples, relieved him in two days perfectly, and he has remained 
well ever since, though this was nearly twenty years ago. 

The second occurred in a boy also eight years of age, whose father 
had died a few years before of phthisis, the younger brother died of 
tuberculous meningitis, and the sister of hooping-cough, with the lungs 
filled with miliary tubercles, as ascertained by a post-mortem examina- 
tion. .The child, after having had fair health previously, was seized, 
towards the end of March, 1865, with frontal headache, very slight fever, 
occasional vomiting, constipation, hesitating pulse, languor, willingness 
to lie abed, and a tendency to somnolence. He was treated with rest, 
milk and beef tea in alternate doses, and mustard foot-baths morning 
and evening; the bowels were kept moderately open, and he took tinc- 
ture of the chloride of iron in combination with dilute acetic acid and 
solution of the acetate of ammonia every three hours. Under this 
treatment he improved, and in ten days had quite recovered. The 
diagnosis at the time was tubercular meningitis in the early stage. 
His mother removed from this city to Washington, where he died on 
the 30th of June of the same year, after an illness of twenty-one days, 
of what was called water on the brain. 

In another case to which one of us was called in consultation, a boy 
whose mother had died a few years before of diabetes mellitus, and 
whose father's family was tuberculous, presented a series of symptoms 
which we could explain only as the result of slow thickening of the 
membranes at the base of the brain, in all probability the result of a 
tubercular deposit. This child had, for several weeks, violent frontal 
headache, constipation, loss of flesh, lassitude, a peculiar one-sided or 
lateral gait in walking, strabismus, and great impairment of vision, so 
that he could see a small object only by bringing it almost in contact 
with the face. There was scarcely any disturbance of the circulation, 
and only slight febrile heat at night. He was treated at first with rest, 
nutritious food, minute doses of bichloride of mercury in combination 
with iodide of potassium, three times a day, and then when he began 
to improve, with tincture of the chloride of iron and cod-liver oil for a 
long period. He finally recovered his health, grew stout and strong, 
but has remained ever since so blind that he reads with great difficulty, 
but manages to pick his way through a room or the street, with only 

32 



498 TUBERCULAR MENINGITIS. 

occasional stumbling. The illness occurred several years ago, and he 
is still living in good general health at this time. 

Are we then to abandon all hope of deriving any good from medical 
means in the disease under consideration ? To this most serious ques- 
tion we ought clearly to respond in the negative. The grounds for en- 
tertaining hope are first, the evidence of M. Guersant that he has seen 
cases which appeared to be tubercular meningitis recover in the first 
stage. Let it be supposed, even, that they were cases of simple inflam- 
mation. But they were undistinguisbable from the tubercular disease 
by one of the most celebrated of modern physicians. Surely, therefore, 
it may happen to men of inferior skill to meet with the same difficulty, 
or if we may so speak, to make the same mistake, if a mistake was 
made. It is said by M. Yalleix that M. Eufz, after determining at the 
autopsy, that a case which he had witnessed was one of simple menin- 
gitis, asserted that it would have been impossible to distinguish it from 
the tubercular disease during life. Again, M. Eilliet has, according to 
M. Yalleix, seen one case of recovery from -what he believed to be the 
tubercular affection, and MM. Eilliet and Barthez, in their second edi- 
tion, as above quoted, assert its occasional curability. We know of the 
occurrence of a case in this city, under the charge of one of our friends, 
than whom we believe no one can be more competent to make a correct 
diagnosis, in which, after the child had j)resented in regular order all 
the early sjniiptoms of the disease, and had arrived at the last and most 
hopeless stage, perfect recovery, to his utter amazement, gradually took 
place. This child, when our friend last heard of it, three months after- 
wards, was in all respects strong and hearty. No doubt the proba- 
bilities are that the case was one of simple meningitis, but who could 
have known this at the time ; and should it not deter us from abandon- 
ing all hope, and, as a consequence, all active treatment, when we seem 
to have under our hands a case of this dreadful malady ? Our own 
cases, given above, also go to prove that the disease is sometimes curable 
in its early stages. 

It is important, in tubercular meningitis, to avoid making a positive 
prognosis as to the period at which death will occur, notwithstanding 
that the patient maj' present every mark of an immediately fatal ter- 
mination. We have already adverted slightly to this subject. On one 
occasion we expected the death of a patient with this malady for three 
days in succession, and on another, we visited a child for a week, dur- 
ing every day of which it seemed as though existence could not endure 
until the next. It had during this time profound coma, subsultus tendi- 
num, and enlarged pupils; the eyelids were half open, the eyes con- 
stantly oscillating, or else rigidly distorted, and both corneas dimmed 
and slightly eroded, from constant exposure to air and light. Convul- 
sions occurred from time to time, the pulse was variable, and at times 
exceedingly frequent, and indeed everything threatened a speedy ter- 
mination. MM. Eilliet and Barthez say, "Often have we inscribed 
upon our notes death imminent^ and been astonished the next day to find 
still alivC; children to whom we had allowed scarcely two hours of life." 

The symptoms which most positively indicate the near approach of 



TREATMENT. 499 

death are, livid color of the face, sweats occurring about the face, 
glassy expression of the eye, dry and incrusted nostrils, and especially 
a very rapid jDulse, and the various nervous sj'mptoms mentioned, as 
carphologia. subsultus tendinum, and general convulsions. 

Treatment. — In the early editions of this work we took the ground 
that it was proper in the early stage of the disease to employ blood- 
letting. Further experience and knowledge compel us to retract this 
opinion. We believe now, that abstraction of blood should not be 
resorted to unless when the diagnosis between this disease and simple 
meningitis is very uncertain. Where there are no marked signs of active 
inflammation, where, from the family history, from the absence of 
marked fever, and the peculiar state of the pulse, we have every 
reason to believe that the low-typed inflammation present is the result 
of the presence of tubercle, we deem it safest to avoid all lowering 
measures. The case is so critical, so almost hopeless from its very 
nature, that we prefer a treatment based on the theory of promoting a 
retrogression of the tuberculous deposit. The only measures which, 
in an experience of over thirty years, we have found to delay and, in 
the cases referred to in the article on prognosis, to cure the disease in 
part, have been the following: quiet of body and mind, obtained by 
means of rest in or on the bed, in a pleasant room, with attendants 
who know how to soothe and still the child. We always insist upon a 
nutritious diet: and one consisting mainly of milk and cream, or the 
two mixed, with beef tea, bread and butter, if the patient will take it, 
or milk-toast, in moderate quantities every three or four hours, a soft- 
boiled egg, or the yelk of a hard-boiled egg, once or twice a day, is 
what we usually endeavor to get the patient to take. A mustard 
foot-bath two or three times a day^ is always safe, and we think useful 
and tranquillizing. The bowels should be moved gently once a day, or 
every two days, by means of an enema or some simple laxative, as 
simple syrup of rhubarb. Active purgation we have found of no use. 
As remedies, we prefer the following: 



R.— Tr. Ferri Ghlorid., 


. . f^J- 


Acid. Acet. Dil., .... 


• . %J- 


Liq. Ammon. Acetat.,. 


. . m- 


Syrup. Simp., .... 


• • f^j- 


Aquae, 


. . f^ijss 



-M. 

A teaspoonful at five years of age, every three or four hours. 

In connection with this, we give half a teaspoonful of cod-liver oil in 
emulsion three times a day. Calomel we have abandoned of late years 
entirely, as it has utterly failed in our hands to do any good. 

Iodine has been very much employed as a remedy in this disease, 
both in the forms of Lugol's solution and iodide of potassium. Perhaps 
the strongest argument which exists in its favor is the benefit which 
often follows its employment in other scrofulous and tuberculous dis- 
eases; though there are several cases in which it is asserted to have 
been successfully used in tubercular meningitis. Iodine itself is com- 
paratively little used. M. Rilliet {op. cit., t. iii, p. 308, 18-17) states that 



500 TUBERCULAR MENINGITIS. 

it has entirely failed in his hands in the tubercular form of the disease; 
the only influence which it seemed to exert was to cause the imme- 
diate suspension of the coma. This was its effect also in a case in 
which we employed it, that of a girl seven years old, to whom we gave 
two droj^s of Lugol's solution three times a day, from the thirteenth to 
the twentieth day, when she died. The day before her death she 
seemed to improve somewhat, and we were in hopes that it had been 
of some service. The amelioration did not continue, however, and we 
are now disposed to believe that the change was one of those which 
often take place naturally in the disease. 

Iodide of 'potassium was recommended more than twenty years ago 
by Eoeser {Huf eland's Journal^ April, 1840), as a remedy of special 
ptower in this disease. It has since then been very widely employed, 
and there are quite a number of cases in which it is asserted that its 
administration has been followed by successful results. 

Dr. West {ojp. cit., 4th Amer. ed., p. 97) thinks that he has seen good 
from its employment, "and that in one instance of what seemed to be 
advanced tubercular hydrocephalus, under the care of my friend and 
former colleague. Dr. Jenner, recovery took place under its employment." 

I^Tiemeyer {op. cit., vol. ii, p. 218) speaks as follows of its use: "On 
the strength of two successful cases, opposed, it is true, by a large num- 
ber of unsuccessful ones, I recommend large doses of iodide of potas- 
sium, continued for a long time." 

Dr. J. Lewis Smith {op. cit., p. 145) also recommends its use through- 
out the entire disease, beginning as early as possible in the premoni- 
tory period. 

Successful cases of its administration are also reported by Drs. Bour- 
rose de Lafore, Coldstream {Edin. Med. Jour., Dec. 1859), and Carson 
{Med. Times and Gaz., March 5th, 1857). 

We have ourselves frequently administered it, either alone or in com- 
bination with small doses of bichloride of mercury, but have not yet 
been fortunate enough to arrest the progress of any case when once 
the second stage has been fully developed. In a few cases, however, 
the use of the following combination : 

Be. — Potass, lodidi, ^j. 

Hydrarg. Chloridi Corrosivi, gr. j. 

Syr. Simp., f^j 

Aquae, f^iij. 

Ft. sol. Dose, a teaspoonful three times a day at five years of age, 

has seemed to delay the march of the disease, in one some weeks, and 
in another, the one already mentioned, it seemed to have a positive 
effect in promoting the absorption of the exudation upon the mem- 
branes at the base of the brain. It is improbable, also, that in all of 
the reported cases, errors of diagnosis were made, and simple menin- 
gitis taken for the tubercular form; so that there is no remedy from 
which so much benefit may be hoped for in this almost hopeless dis- 
ease, as iodide of potassium in full doses, and it should therefore be 
faithfully tried whenever opportunity offers. We have been in the 



TREATMENT. 501 

habit of giving it in doses of one or two grains every three or four 
hours, to children two years of age. It has, however, been given to 
the extent of a drachm in the course of a single day to children of that 
age. It ought to be begun with early in the case, and continued in 
connection with counter-irritation and cold to the head. We must re- 
mark, however, that it sometimes irritates the bowels too much, caus- 
ing diarrhoea; and here the dose ought to be greatly reduced, or the 
remedy withdrawn. 

The treatment which has just been described is that which we have 
been led by our convictions as to the nature of the disease, and b}^ our 
personal experience of different plans, to adopt as the most reasonable 
and the best. It is proper to state, however, that we have never seen 
it, nor any other method, of any avail after the disease has passed into 
the latter part of the second stage — when coma, dilatation of the pupils, 
marked strabismus, paralytic or convulsive phenomena, show the pres- 
ence of inflammatory exudation under the membranes, and of serous 
effusion into the lateral veiitricles, or the peculiar lesions of the sub- 
stance of the brain, which exist at tbat period of the malady. It is 
also proper to add that other means have been recommended by high 
authorities, and to these we shall now devote some remarks. 

Counter -irritation in different forms has been employed, and appar- 
ently with success, though it has failed in our hands. Blisters to the 
nucha, behind the ears, or over the whole scalp, have been used. At 
one time, in this city, it was a common practice to cover the scalp with 
a blister, but it was found to fail so constantly, and was so painful a 
sight to the relations of the child, that it has been very much aban- 
doned. Surely, if it had succeeded in any considerable proportion of 
the cases, it would have been received as a boon, however revolting to 
the sight. We have, ourselves, in past years, blistered the nucha, the 
back of the ears, and the temples in a number of cases, but have always 
failed to obtain any evident good from them. Within a few years it 
has been claimed that pustulating the whole sinciput with croton oil 
has been of great service. The last case of tuberculous meningitis we 
saw, occurred in an adult, and here we had nearly the whole of the 
crown of the head shaved, and pustulated with the oil, but it was of no 
use whatever. 

Cold applications to the head have been very much used. We have 
employed them ourselves, and still use them whenever the head is hot, 
or when their use relieves the headache or soothes the patient, but we 
confess that they have not seemed to us of much use except as pallia- 
tives. They may consist of cloths wet with cold water, of affusions 
with cold water, or, as has been proposed by M. Guersant, of irriga- 
tion as employed in surgery. M. Guersant prefers this mode of appl}^- 
ing cold to any other, believing it to be the most convenient and com- 
fortable to the child, and from its continuous action, the most efficacious. 
To make use of it, the hair is to be shaved or closely cut, and the child 
placed upon a mattress without a pillow, and with its head near the 
edge of the bed. The head is then covered with compresses of soft 
rag, or, better still, of patent lint, while under it is placed a piece of 



502 TUBERCULAR MENINGITIS. 

oiled silk or india-rubber cloth, so arranged as to keep the thorax from 
being wet, and doubled into a gutter above to convey the water off into 
a vessel placed on the floor, A bucket or basin filled with fresh, cool 
water, is placed near the head of the bed, and from this a siphon made 
of lint or lamp-wick is so arranged as to convey a stream of water upon 
the compresses covering the head. If the heat of the whole body falls 
so much as to threaten collapse after the irrigation has been continued 
for some time, the stream of water should be stopped, and compresses, 
merely wet with water not quite so cool, kept on the head. The latter 
precaution is necessary in order to prevent injurious reaction from the 
sudden and total removal of so powerful a sedative as irrigation proves 
to be. 

Some practitioners prefer the use of ice in a bladder. This seems^ 
however, too severe a remedy to be long continued, and we should 
therefore rather use only cloths wet with iced-water, or irrigation. 
Dr. Abercombie is of opinion that the application of cold is by far 
the most powerful local remedy that we have. M. G'endrin recom- 
mends cool or cold affusions over the whole surface, the temperature 
to be proportioned to the heat of the skin. When there is but little 
heat of head, only a slight febrile movement, and the headache is not 
relieved by cold applications, Guersant recommends the substitution of 
warm poultices to the scalp, in the place of irrigation or cold applica- 
tions. 

We have already stated that calomel has not succeeded in our hands, 
so that we have abandoned its use. We deem it right, however, to lay 
before the reader the opinions of others upon this point. Thus, it is 
highly recommended by many of the English writers on acute hydro- 
cephalus, and is asserted to have effected cures when it has been pushed 
to such an extent as to produce salivation. But little dependence, how- 
ever, can be placed on these assertions, as in all probability the reported 
recoveries occurred in cases of simple meningitis. The French writers 
speak of having used it in very large quantities without any success. 
It was given to many of the patients of MM. Eilliet and Barthez, in the 
quantity of from six to ten, increased to twenty grains, in twenty-four 
hours, in connection with frictions with mercurial ointment, of which 
two drachms and a half were used at first, and the quantity afterwards 
doubled and trebled. They state that salivation did not occur in any 
of the cases, though fetor of the breath and inflammation of the gums 
were of frequent occurrence. Calomel may be given, as has been re- 
marked, in purgative doses^ at the beginning, and for the purpose of pro- 
curing its specific effects. With the latter view the dose may be from a 
quarter of a grain to a grain, every hour or two hours. Mercurial inunc- 
tion, in conjunction with the internal administration of the remedy, has 
been highly recommended by several writers as an efficient means of 
procuring the full effect of the drug upon the constitution. About a 
drachm of the ointment is to be rubbed into the iusides of the arms and 
thighs morning and evening, and the quantity gradually increased if 
no effect is produced. For our part, we will merely state that we have 
never known calomel given in large quantities, in order to procure 



TREATMENT — USE OF CALOMEL. 503 

salivation, of the least benefit in the disease. On the contrary, we can- 
not but think that the violent irritation of the digestive mucous mem- 
brane which it has determined, whenever we have used it largely, and 
the inflamed, irritated condition of the mouth which it caused in one 
case, must have been a serious aggravation of the state of disease under 
which the constitution was laboring. Mercury is well known to be an 
injurious and dangerous remed}^ in the tubercular diseases of adults, 
having for its effect to increase the d^^scrasia of the constitution, wliich 
already exists, and thereby to hasten the progress of the malady. Why 
it should have a different effect in children is difficult to understand. 
It may be said, to be sure, that in the disease we are considering, it is 
given to overcome the inflammatory element of the malady, which, for 
the time, constitutes the danger of the case, and also to allow the patient 
the chance of its beneficial operation should the disease happen to be 
one of simple meningitis. In support of the views just expressed, we 
will quote the opinion of Dr. John Abercrombie {Diseases of the Brain 
and Spinal Cord, Philad. ed., 1831, p. 173-6): "Mercury has been 
strongly recommended in that class of cases which terminates by hy- 
drocephalus, but its reputation seems to stand upon very doubtful 
grounds. In many cases, especially during the first or more active 
stage, the indiscriminate employment of mercury must be injurious. . . . 
In the preceding observations, I shall perhaps be considered as having 
attached too little importance to mercury in the treatment of this class 
of diseases, particularly in the treatment of hydrocephalus ; but in doing 
so, I have stated simply what is the result of an extensive observa- 
tion, . . . and I confess, the result of my observations is, that when 
mercury is useful in affections of the brain, it is chiefly as a purgative." 

It has been recommended, within a few years, by Sir B. Brodie, to 
employ mercurial inunction as especially applicable in using mercury 
for children. He advises that a drachm or more of the ointment be 
spread upon one end of a flannel roller, which is to be applied, not very 
tightly, around the knee; repeating the application daily. "The mo- 
tions of the child produce the necessary friction ; and the cuticle being 
thin, the mercury easily enters the system." The editors of the journal 
in which this communication is made (Braith. Retrosp. of Med., vol. iv, 
1846, p. 147, from Quart. Med. Bev., July, 1846, p. 169), state that they 
tried this plan in a case of acute hydrocephalus, in which some of the 
most urgent and fatal symptoms were present, " such as very dilated 
pupils, constant convulsions, hemiplegia, and more or less stertorous 
breathing; in short, so violent were the symptoms, that we considered 
the case perfectly hopeless; but on reflecting on Sir Benjamin's method, 
we ordered strong mercurial ointment to be smeared on each leg, every 
twelve hours, and covered with a stocking made to tie tightly above 
the knees. The symptoms soon began to abate, and by following this 
up with small doses of iodide of potass., frequently repeated (gr. i, every 
three or four hours), the head symptoms vanished. 

"In a second case, the same set of symptoms were approaching, but 
were stopped by the same mode of treatment." 

When the convulsive symptoms are violent and distressing, they may 



504: TUBERCULAR MENINGITIS. 

often be moderated by the use of a warm bath, which must be carefully 
given, and by the administration of some of the antispasmodics. We 
prefer for this purpose the fluid extract of valerian, of which from ten 
to twenty drops may be exhibited every two or three hours to young 
children, and a larger dose to those who are older. Bromide of potas- 
sium has also been recommended on account of its peculiar sedative 
action, and M. Bazin {Gaz. de Sopitaux, 1865) narrates a case in which 
large doses of this remedy were successful in checking the progress of 
tubercular meningitis, in a lad who presented at the same time the 
symptoms of pulmonary tuberculosis. 

As a general rule, narcotics of all kinds are to be avoided, from their 
effect of increasing the constipation, and exciting more or less the cere- 
bral circulation. When, however, neither antiphlogistics, evacuants, 
nor cold or warm applications relieve the sufferings of the child, it would 
be proper to employ small laudanum poultices or opium plasters upon 
the forehead or temples, or we may use morphia by the endermic 
method. 

The treatment described in the preceding pages, is that which is 
proper for cases of the disease occurring in subjects previously in good 
health, or evincing but few signs of the tubercular cachexia. When, on 
the contrary, it occurs in children with extensive tubercular affections 
of other organs, by which they are already weakened and exhausted, 
the treatment must of course be modified to meet the circumstances of 
the case. It ought to consist chiefly of cold applications, and of an 
early use of cod-liver oil, of iodine, or of the iodide of iron. We should 
recollect that experience has long since shown the weakness of our art 
in such cases, and for that reason avoid such a degree of interference as 
might possibly abridge the little span of life allowed the patient by this 
relentless malady. 

Prophylactic Treatment. — It must be evident that the prophylactic 
treatment is of especial importance in a disease so little amenable to 
curative means as the one under consideration. When, therefore, 
there is reason to suspect a tendency to tubercular meningitis in a 
child, either from the fact that other children- in the family have per- 
ished with it, or from a bad state of the general health and frequent 
complaints of headache, it becomes proper and necessary to regulate 
both the moral and phj^sical education with a view to its preven- 
tion. For this end the hygienic management of the child ought to be 
such as is best calculated to prevent the formation or development 
of tubercles in the constitution. During infancy, such a child should 
be nursed, if this be possible, by a strong, hearty woman, with an 
abundant flow of milk. If the mother is not possessed of these quali- 
ties, if there be, indeed, the least doubt upon the point, she ought with- 
out hesitation to give up the pleasure of nursing the child herself, and 
procure foi- it a wet-nurse of the kind described. This alone will, in 
all probability, often make the difference between a vigorous and a 
fragile constitution. When the time for weaning arrives, the change 
ought to be made with the greatest care and circumspection. During 
and for some time after weaning, the diet must consist principally of 



PROPHYLACTIC TREATMENT. 505 

milk preparations and bread, and of small quantities of light broths, 
or of meat very finely cut up. As the child grows older, the meals 
ought to be arranged at regular hours, and should consist of four in 
the day. The principal food must be bread and milk, well-chosen, well- 
cooked meats, and rice and potatoes as almost the only vegetables. 
After the first dentition is completed, a moderate use of ripe and whole- 
some fruits may be allowed, but alwaj^s with care, in order to avoid in- 
jury to the digestive organs, and also so as not to mar the appetite for 
more wholesome and nutritious food. Coffee and tea ought to be for- 
bidden at all times; since, as we have often observed, when the palate 
of a child is taught, by habit, to become accustomed to these more 
highly sapid substances, it is very apt to abandon the use of milk, 
which ought to constitute a large proportion of its food, at least up to 
the age of twelve or fifteen years. In no circumstances of life is the 
old saying, '' where ignorance is bliss, 'tis folly to be wise," a better 
rule of action than in regard to the diet of our children. The child 
should not taste improper articles of food, so that it may escape the 
torment of desiring what is improper. 

After diet the most important points in the treatment are air and 
clothing. The child should inhabit, if possible, a large, dry, well-ven- 
tilated room, which ought to be kept as cool as possible in summer, and 
moderately warm in winter. Not a day should be allowed to pass, un- 
less the weather is totally unfit, without the child's being sent for sev- 
eral hours into the open air, and we believe that it is much better for it to 
walk than drive, unless the weather be very hot. The clothing ought 
to be suitable to the season, cool in summer and warm in winter. In 
our countr}^ there is a great inclination to harden children by dressing 
them very slightl}' in cold weather; so that they frequently suffer from 
catarrh, pneumonia, and spasmodic croup brought on by improper ex- 
posure. This cannot but be wrong in a child who shows the least evi- 
dence of a tendency to tubercular affections. 

For our own part we are fully convinced from what experience we 
have had of the diseases of children, that by far the most certain and 
effectual means of preventing the development of a tubercular, or in- 
deed any other cachexia in a child, is to have it brought up in the open 
country, or in some healthy village, until the epoch of puberty has 
passed by safely. A very good plan for parents whose occupations 
compel them to live in cities or large towns, is to have their residence 
a few miles in the country, and to come to town every day. Children 
brought up in this way have a far better chance of obtaining strong 
and vigorous constitutions, than those reared entirely in the close and 
confined dwellings and streets of crowded cities. 

When a child, who, from the health of its parents, or from its own ap- 
pearance, ma}^ be suspected of having any tubercular or scrofulous taint 
in its system, becomes subject to frequent attacks of apparently cause- 
less headache, and especially when such headaches are associated with 
a constipated habit of body and with occasional vomiting, it ought to 
be looked upon as threatened with tubercular disease of the brain. 
Under these circumstances we would advise, in addition to the meas- 



506 TUBERCULAR MENINGITIS. 

nres just now recommended as to diet, dress, exercise in the open air, 
and a residence in the country, that it be put at once upon the use of 
cod-liver oil, iodide of iron, and mild laxatives, and that these be per- 
severed in for several weeks or months, until in fact the strength and 
general health are restored and the headaches cease. When the appe- 
tite is poor, and the digestion is imperfect, in such a case we may use 
with advantage, besides the above remedies, solution of pepsin, a tea- 
spoonful three times a day with the mealS; or tincture of nux vomica, 
three or four drops in a mixture of syrup and compound tincture of 
gentian, or in a teasj^oonful of elixir of cinchona three times a day. 
If the child is of an age to be going on with its education, this shotild. 
for the time cease, or be carried on in such a way as to avoid all excite- 
ment or fatigue. A case occurred to one of us in the course of the 
year 1852, which showed, we think, very clearly the utility of these 
measures. 

A boy between seven and eight years old, whose mother had died of well-marked 
phthisis a few months before he was put under our charge, had been losing flesh and 
strength, and suffering from occasional headache for some time before we were called 
to see him. We found him in bed complaining of severe frontal headache; so severe 
at times, and usually in the after-part of the day, as to cause great distress, with 
crying. The intelligence was perfectly natural. The child was rather dull and list- 
less, from suffering and from weakness, but not from any want of a healthful state 
of the mental operations. There was no sign whatever of spasmodic or paralytic 
affection. In the morning the skin was cool and natural, but in the afternoon it be- 
came warm and dry, but not very hot. The pulse was 62 to 68, and though not actu- 
ally irregular, it was halting or hesitating. There was occasional, but not frequent, 
unprovoked vomiting, and he complained often of sick stomach, even when he did 
not vomit. The bowels were very much constipated, and had been a good deal so for 
some weeks previous to his falling actually sick. There was no cough, no sore throat, 
and no soreness about the abdomen. The tongue was moist, soft, slightly furred, and 
not red nor gashed. The urinary secretion was healthy. Physical examination 
showed the lungs and heart to be without disease. 

The treatment during the first week was small doses of calomel and rhubarb, half 
a grain of the former to two of the .latter, given for a day, and followed by syrup of 
rhubarb and fluid extract of senna, until the bowels were copiously evacuated. After 
this the bowels were kept soluble by the administration every day, or every other 
day, of doses of Seltzer powder, sufficient to produce the effect. Blisters were applied 
behind the ears. In the after-part of the day, when the head and body became heated, 
cooling applications were made to the head, and the feet were put into mustard-water, 
once, twice, or three times. Two grains of iodide of potassium were ordered to be 
given three times a day. The diet was to be light but nutritious. It was to consist 
of bread and milk and a soft-boiled egg in the morning, oysters or light meats with 
rice for dinner, and milk with bread in the evening. Of these he was to have any 
reasonable quantity that he might desire. Under this treatment he improved slowly, 
with occasional drawbacks for a week, when the iodide of iron was substituted for 
the iodide of potassium. The bowels continued very costive, requiring daily doses 
of the Seltzer powder ; the headaches diminished in frequency, duration, and severity ; 
the pulse went up to 72 and 78, and became more free and even ; the appetite had im- 
proved, but the child remained still very weak, pallid, and quite emaciated. After 
another week, as he continued to mend, and the stomach had become stronger, cod- 
liver oil was ordered in addition to the iron ; a teaspoonful was to be taken three 
times a day in a wineglassful of table-beer. As he gained strength, the amount and 



SIMPLE MENINGITIS. 507 

kind of food was increased. He was, indeed, encouraged to eat heartily of plain and 
digestible substances. 

He now improved gradually in health. The headaches subsided, and finalh'- ceased j 
the bowels became soluble ; the appetite grew hearty and strong, and all feeling of 
nausea disappeared; he regained his strength, flesh, and color, so that at the end of 
two months we saw him looking quite fat and well. The iodide of iron and cod- 
liver oil were, however, to be continued for a month longer. He is now (1869) a 
young man in very good health. He has passed several years in Germany pursuing 
a scientific education, and has returned lately to this country, and is about to marry. 

As to the particular means likely to be of service in preventing a 
direction of the tubercular cachexia towards the brain, such as might 
produce tuberculosis of that organ, we have only to propose the course 
recommended by different writers, viz., to keep the head cool by not 
allowing it to be very warmly covered, and by keeping the hair short ; to 
keej) the extremities warm; to avoid stimulating the intellectual facul- 
ties to any considerable extent by education, until after eight or ten 
years of age; and to use every means to preserve the general health in 
a sound and pure condition. Some recommend the long-continued em- 
ployment of a powerful derivative from the brain, as a small blister on 
the arm or a seton in the neck. We think, however, that such reme- 
dies ought not to be used unless there are positive symptoms of a tend- 
ency to cerebral disorder. The caution not to interfere much by pow- 
erful local applications, with eruptions which nature may have thrown 
out upon the scalp, is, we believe, wise and prudent; though there can 
be no objection to the administration of suitable internal remedies with 
a view to their cure. 



AETICLE 11. 

SIMPLE MENINGITIS. 

Definition; Synonyms; Frequency. — By this term is understood 
inflammation of the membranes of the brain, independent of tubercu- 
losis of those tissues, or of other organs of the economy. 

The disease was for a long time confounded with tubercular menin- 
gitis under the titles of water on the brain, dropsy of the brain, and 
acute hydrocephalus. It has also been called arachnitis; and more 
rarely phrenitis. 

Its frequency is much less than that of tubercular meningitis. West 
(op. cit., 4th Amer. ed., p. 100), states that he has seen 7 cases of fatal 
acute meningitis, in 5 of which post-mortem examination was made 
and confirmed the diagnosis. Yogel {op. cit., p. 359) speaks of it as 
being much rarer than the tubercular form, and states that it is no 
more frequent in children than in adults. It appears that MM. Eilliet 
and Barthez, during their researches, met with only five cases of this 
disease, while they report thirty -three of tubercular meningitis. Bou- 



508 SIMPLE MENINGITIS. 

chut states that he has met with two cases of simple meningitis to six 
of tubercular disease, whilst Barrier reports only four of the former in 
nearly thirty autopsies of meningitis. He states, however, that he has 
met with three cases of recovery, all of which he believes to have been 
instances of the simple form. Fabre and Constant met with nine cases 
of simple to twenty-seven of tubercular meningitis in a period of two 
years, at the Children's Hospital of Paris. (Bibliotheque du Med. Prat., 
t. vi, p. 166.) 

Causes. — The causes of simple meningitis are not very clearly ascer- 
tained. It would appear, however, that the disease is more common in 
inftmts than older children. M. Eilliet, who published a very valuable 
paper on this affection {Arch. Gen. de Med., t. xii, 1846), divides it into 
two forms, the convulsive and phrenitic, the former of which he be- 
lieves to be most common under two, and the latter between five and 
fifteen years of age. This author is disposed to think, from the fact 
that the disease is most frequent in the first and ninth years of life, 
that the process of dentition has something to do in its production. It 
appears also to be more frequent in boys than girls, and in robust than 
in weak constitutions. Gruersant has known it to follow long-continued 
exposure to the sun in several instances, particularly in young infants; 
MM. Eilliet and Barthez report a case of the same kind, and Eilliet 
(loc. cit.) another; other causes cited by authors are injuries upon the 
head, such as blows, falls, and wounds. It also occurs as a consequence 
of extension of inflammation to the membranes of the brain, and usually 
from the internal ear in cases of otorrhoea. 

The disease sometimes occurs in an epidemic form, and usually in 
conjunction with inflammation of the spinal meninges, constituting 
the disease which has been carefully studied of late years, known as 
cerebro-spinal meningitis. 

Anatomical Lesions. — The dura mater is generally much injected, 
and its sinuses, together with the large cerebral veins, contain coagu- 
lated or semi-coagulated blood, sometimes in large quantities. On 
opening the dura mater, the whole, or nearly the whole of the convex 
surface of both hemispheres, or in some instances of one only, are found 
to be covered with a yellowish or greenish-yellow layer, which consists 
of fluid or concrete pus, or of false membranes. These deposits exist 
also on the internal surfaces of the hemispheres, on the upper surfaces 
of the cerebellum, and often also at the base of the brain, though in 
some cases the latter presents none whatever. The inflammatory prod- 
ucts are seated in the pia mater, and sometimes in the cavity of the 
arachnoid membrane, but in much smaller quantity than in the tissue 
beneath that membrane. 

The arachnoid membrane which covers the brain seldom participates 
in the inflammation, but remains smooth and transparent. Its cavity, 
however, sometimes contains inflammatory products, which, when death 
occurs early in the attack, consist of a small quantity of pure pus, or 
of larger quantities of a turbid, yellowish serosity, consisting of serum 
and pus mixed together. When death has occurred later in the dis- 



ANATOMICAL LESIONS. 509 

ease, — after five, six. or seven days, — the pus is mixed with lymph, or 
else true false merahranes are found. The pia ynater is observed to con- 
tain fluid or semifluid pus when death occurs before the fourth or fifth 
day; while in less acute cases there are patches or large layers of 
lymph, which sometimes dip into the anfractuosities, and give to the 
membrane nnder consideration a swelled and thickened appearance. 
These appearances are more marked on the superior and lateral, than 
on the inferior surface of the brain. Where the deposits exist the mem- 
brane presents a vivid injection, which is more marked in proportion as 
death has taken place earlier in the disease. The pia mater is gener- 
ally easily detached from the cerebral substance, particularly when the 
fatal termination has occurred early. The substance of the brain is firm, 
and but slightly colored, in rapid cases. When the course of the dis- 
ease has been slower, the cineritious portion is generally of a bright 
rose color, and the medullary substance abundantly dotted with red, 
showing that the inflammation has involved the superficial layer of 
the brain. In the latter class of cases the surface of the convolutions 
is usually softened, and the pia mater adherent. In very young chil- 
dren the whole brain is sometimes soft. 

The ventricles do not, as a general rule, contain transparent serum, 
except at a very early age, when serous effusion takes place with great 
facility. They, often, however, contain one or two teaspoonfuls, and 
rarely more than one or two tablespoonfuls, of pus or purulent serum. 
The serous membrane of the ventricles and the plexus choroides ex- 
hibit signs of inflammation in some instances. They are of a bright red 
color, uneven, rough, and very much softened, in children who die 
early; and pale, opaque, slightly thickened, and rough, in those who 
die at a later period. 

The central parts of the brain often retain their firmness, but are 
sometimes softer than natural, or even diffluent. This softening is par- 
ticularly apt to exist in very young children, in connection with large 
effusion into the ventricles; though it also occurs in those who are 
older, and in whom there is only slight effusion of pus or purulent 
serum. In the former case it is probably due to the macerating efl'ect 
of the effusion, while in the latter it is more likely to be owing to in- 
flammation. 

In some cases, and especially those of the epidemic form of the dis- 
ease, the membranes of the spinal cord are found to present the same 
inflammatory appearances which have been described as existing in the 
cerebral meninges. These cases are, therefore, more correctly desig- 
nated by the name cerebro-spinal meningitis. 

The other organs are healthy except in secondary cases. Tubercles, 
which so constantly exist in various oth"er organs in tuberculosis of the 
meninges, are never found, according to M. Eilliet, in this form of men- 
ingitis. This author believes himself entitled from his researches to 
formulate the following law of pathological anatomy : " That general 
meningitis and meningitis of the convexitj^ of the brain occur only in 
non-tuberculous children, whilst meningitis of the base of the brain 



510 SIMPLE MENINGITIS. 

without inflammation of the lining membrane of the ventricles, belongs 
exclusively to tuberculous children." (Op. cit., t. iii, 1846, p. 408.) 

This law cannot, however, be adopted without exception, since we 
have already seen, when speaking of tubercular meningitis, that there 
are, in a large proportion of such cases, evidences of inflammation of 
the lining membrane of the ventricles. 

Symptoms. — The following account of the symptoms of the disease is 
taken chiefly from the paper of M. Eilliet. That author describes two 
forms of the aflpction, the convulsive and phrenitic ; the former of which 
is characterized by a predominance of convulsive phenomena, and the 
latter by disorders of the intelligence. 

The disease may also be idiopathic or secondary, simple or compli- 
cated, sporadic or epidemic. 

The convulsive form generally occurs in children under two years of 
age. The disease usually begins suddenly or after a restless night, 
with a violent and prolonged attack of convulsions, oftener general than 
partial, and is accompanied by violent /euer, and sometimes by consider- 
able quickness of respiratio7i. The existence of headache cannot be as- 
certained at this early age. Yoiniting is often absent, and the boivels 
generally continue regular in this form, though they are sometimes 
constipated. After awhile the convulsions cease, and the child re- 
mains for the time in a state of quiet, somnolence, or coma, when they 
return with renewed violence. The returns of the convulsions gener- 
ally take place at intervals of one or two hours or more. In the in- 
tervals between the crises the child is restless or drowsy, or in a state 
of partial stupor, attended with tremulous movements of the extremi- 
ties; there is strabismus, contraction of the pupils, trismus, and sometimes 
hemiplegia. The skin retains its warmth, the pulse is accelerated, 
irregular, and unequal; the face is joale; the stools are spontaneous or 
easily procured by remedies. It is unusual to see the child regain its 
consciousness so as to recognize objects in the intervals between the 
convulsions, or after the appearance of coma and other cerebral symp- 
toms. Death occurs during coma or in a violent attack of convulsions. 
This form seldom lasts more than four days. 

Occasionally this form begins in a different manner. The convul- 
sions, though they still predominate, do not occur until later in the 
disease, and the whole course of the affection is slower. Such cases 
begin with a violent febrile movement, lasting several days, and ac- 
companied by acceleration or unevenness of the respiration, or by 
almost constant drowsiness, preceded or followed by agitation, scream- 
ing, staring expression of the eyes, and dilatation of the pupils; vomit- 
ing and constipation are sometimes present, at others absent. After a 
time, however, convulsions make their appearance, and the case fol- 
lows the course already described. The duration of this form may be 
the same as that of the first, or it may last about two weeks. 

The phrenitic form of simple meningitis generally begins suddenly 
with fever, which is sometimes preceded by a chill; the skin is warm 
and dry, and the pulse, in idiopathic cases, full and accelerated. In 



SYMPTOMS. 511 

secondary cases the pulse has been found slow and irregular; in all it 
becomes irregular, small and very rapid the day before death. Simul- 
taneously with the fever there is frontal headache, which is often so 
violent as to draw cries from the child, and, according to M. Eilliet, is 
more severe than either in tubercular meningitis or typhoid fever. It 
is also more constant, and lasts generally one, two, or three days, 
until the appearance of restlessness, delirium, or coma. At the same 
time there is great sensibility to light and noise, and abundant vomit- 
ing of bilious matter. The latter symptom is one of the earliest; it 
generally ceases after a few days, but sometimes continues to the very 
end. Constipation exists in some cases, but is much less constant and 
more easily overcome than in the tubercular disease. The appetite is 
lost, and the thirst very acute. The abdomen is flattened and retracted, 
especially towards the end, while in secondary cases of this form, and 
in very young children, it retains its usual shape. 

About the end of the first day, generally, or, in rare instances, after 
two or three days, appear various disorders of the intelligence. The 
first symptom of this kind is observable in the expression of the face, 
which becomes a little wild or wandering, and sometimes grimacing. 
Soon afterwards occur restlessness, which is sometimes extreme, and, 
in succession, delirium, somnolence, and later in the attack, coma. The 
restlessness and somnolence often alternate early in the case, though 
the former generally predominates and soon passes into delirium, which 
is usually violent. When in this condition the child seldom recognizes 
any one, and either refuses to answer questions, or answers incoher- 
ently. In connection with the disorders of intelligence there exist 
also trismus, grinding of the teeth, subsultus tendinum, partial convul- 
sive movements, stiffening of the extremities or trunk, retraction of 
the head, strabismus, contraction first and then dilatation of the pupils, 
and in some cases violent convulsions, followed by deep coma. Death 
sometimes occurs at thisperiod. In other instances, the disease con- 
tinues longer, and other symptoms declare themselves. Yomiting gen- 
erally ceases; constipation increases; the abdomen is retracted ; head- 
ache is no longer complained of; the fever continues, but the pulse 
becomes irregular; the respiration is uneven and irregular, being some- 
times more and at other times less frequent than natural; the face is 
distorted and extremely pale, or there may be a purple flush on the 
cheeks; the restlessness is excessive, and accompanied by subsultus, 
carphologia, or partial convulsive movements; the delirium, at first so 
violent as to make it necessary sometimes to hold the child in bed, 
subsides into a state of coma and collapse, in which general sensibility 
is obtunded, and special sensibility extinguished ; the respiration be- 
comes stertorous, and at length asphyxia, coma, or a severe attack of 
convulsions terminates the scene. 

The course of the disease is generally continuous. In very rare cases, 
however, occasional remissions occur, so that the child recovers its in- 
telligence for a short time, and recognizes persons around. The dura- 
tion has varied between a day and a half and nine days. 



512 SIMPLE MENINGITIS. 

Diagnosis. — The convulsive form may be confounded with the essen- 
tial or symptomatic, and with the sympathetic convulsions of children. 
The mistake may generally be avoided by attention to the following 
points. In essential convulsions, the attacks are usually less violent, 
seldom last more than a few moments, occur from some evident cause, 
and do not recur often. When they have ceased, the child generally 
soon regains its consciousness and health, or exhibits slight drowsiness, 
or derangement of movement for a short time only. In such cases the 
respiration is not permanently accelerated, as in convulsive meningitis; 
the pulse, if it has been increased in frequency, soon falls to the natural 
standard, and special sensibility remains undisturbed. 

It is to be distinguished from sympathetic convulsions by the char- 
acters just described, aided by a reference to the disease which may 
have caused the attack of eclampsia, and which may be one of the erup- 
tive fevers, enteritis, indigestion, pneumonia, or any other acute affec- 
tion. In some instances, however, the distinction cannot be made except 
by attention to the progress of the attack. 

The phrenitic form may be confounded with tubercular meningitis, 
with congestion of the brain, or with the early stage of the eruptive 
fevers. The distinction between it and tubercular meningitis has al- 
ready been considered under the head of the latter disease. 

M. Eilliet is of opinion that it is sometimes impossible in the present 
state of knowledge upon these points, to distinguish with certainty be- 
tween simple meningitis and cerebral congestion or hemorrhage, and 
encephalitis. In regard to congestion of the brain, he proposes the 
very important question, "Whether we ought to class as meningitis the 
dangerous cerebral s^^mptoms, resembling exactly those which mark 
the commencement of meningeal inflammation, and terminating rap- 
idly by death or recovery?" He states that examination after death 
in these cases reveals neither pus nor false membranes in the arachnoid 
or pia mater, but simple congestion of the brain and its membranes. 
He deems the solution of the question to be difficult, but is himself of 
opinion that they ought not to be classed together. He gives the fol- 
lowing table, which he thinks may assist in making the diagnosis : 

CONGESTION OF THE BRAIN — MODE OE MENINGITIS. 

INVASION. 

There occurs instantaneously profound In the phrenitic form the first symp- 
stupor, absolute immobility and insensi- tom is generally headache, which is not 
bility, with dilatation of the'pupils; or noted in any of the cases of M. Bland (of 
else acute delirium, with difficulty of congestion). The alterations of intelli- 
breathing, and with acceleration and gence and motion occur early, but not be- 
smallness of the pulse ; or in yet another fore the beginning of the first or second 
class of cases with tremors or slight con- day ; whilst in congestion, the appearance 
vulsive movements of one side of the of delirium or coma, of subsultus tendi- 
body. Stuttering, loss of speech, stertor- num, or partial paralysis, is instantane- 
ous respiration and pains in the arms and o us, frightful, truly apoplectic, and, so far 
corresponding side of the face exist; the as we can ascertain, not accompanied by 
fingers do not retain objects which the vomiting, — a symptom rarely absent in 
child attempts to grasp. meningitis. 



PROaNOSIS — TREATMENT. 513 

From the invasion of variola, it is to be distinguished by attention 
to the contagions and epidemic nature of that malady, by the inquiry 
as to whether the patient has been vaccinated or has had a prior at- 
tack of that disease, by the absence of pains in the loins, in meningitis, 
and by a consideration of the period at which the delirium makes its 
appearance, which, in variola, rarely occurs before the third day. To 
make the diagnosis between meningitis and malignant scarlatina, we 
must attend chieflj^ to the epidemic and contagious character, to the 
thick coating upon the tongtie, redness of the throat, elevated tempera- 
ture, and nasal respiration, which exist in the latter. 

Prognosis. — The prognosis of simple meningitis is very grave, but 
much less hopeless than in the tubercular form. M. Yalleix is disposed 
to think that most of the recoveries reported by M. Guersant were 
cases of sanguine congestion or effasion. M. Eilliet {loc. cit.), who has 
studied the subject more carefully than any other observer, cites several 
instances of recovery, but states that death is much the most frequent 
termination. 

Treatment. — It must be evident, it seems to us, that but little de- 
pendence can or ought to be placed on any but prompt and powerful 
antiphlogistic treatment. Bloodletting ^ therefore, mercury^ cold applica- 
tions to the head, purgatives^ counter-irritants^ and the most rigid diet 
ought to be employed from as early a period as possible, and in the 
most energetic manner. 

Venesection ought alw^ays to be preferred to local bleeding, even in 
the youngest child, unless it is impossible to find a vein, or unless this 
is evidently too small to bleed well. When venesection cannot, from 
any reason, be employed, blood should be freely drawn by means of 
leeches or cups. It is customary to apply the leeches to the temples 
or behind the ears. We may remark that MM. Eilliet and Barthez 
object to the application of leeches to the head, and propose that they 
should be placed rather about the anus or on the inferior extremities. 
The quantity of blood to be drawn must depend upon the age and con- 
stitution of the subject, and the violence of the attack, in some measure. 
It should always, however, be large, as much or more, we think, than 
is necessary in any other of the acute affections of childhood. In a 
child two years old, of good constitution, from two to four ounces 
would not be too much at first, and should the symptoms not moderate 
in six or eight hours, as much more may be taken. Should these de- 
tractions of blood fail to produce a good effect upon the dangerous symp- 
toms, it would be proper, unless there were evident and unmistakable 
signs of exhaustion, to take still more, either locally or generally. We 
are disposed to believe that in such a disease as this, bleeding is by far 
the most powerful remedy, and it is perhaps the only one which offers 
us any real chance of success, at least in those rapid cases in which 
extensive layers of pus and false membranes are found on the surface 
of the brain, in the pia mater, or in the subarachnoid tissue, in from 
two days and a half to three or four days after the commencement of 
the disease. 

33 



514 SIMPLE MENINGITIS. 

While the bleeding is being performed we should direct the prepara- 
tion of means for the application of cold to the head, which constitutes 
another most efficient remedy in inflammations of the brain and its 
membranes. These means may consist of a bladder containing water 
and pounded ice, which is perhaps the most convenient and powerful, 
of cloths wrung out of iced or very cold water, to be constantly renewed, 
of cold affusions upon the head, or lastly, of irrigation as recommended 
by M. Guersant, and described in the article on tubercular meningitis. 
Purgatives ought to be employed so as to empty the bowels thoroughly, 
and produce a decided revulsion upon the intestinal mucous menibrane, 
but not in such quantity as to occasion inflammation of that tissue, 
which would be very apt to prove the case were the drastic substances 
and large doses recommended by some writers used. The remedy 
usually given and most highly recommended is calomel, which is chosen 
for its sedative and alterative properties. About four grains may be 
exhibited alone, and followed in one, two, or three hours by castor-oil, 
jalap, or infusion of senna and manna, sweetened with syrup of rhubarb. 
These doses ought to be given until the bowels are freely moved. It 
is always useful to employ a strong purgative enema immediately after 
the bleeding, without waiting for the operation of the internal remedies. 
After the purgative doses have been given, it is important to continue 
the mercury in smaller quantities, with the view of obtaining its specific 
influence upon the inflammation. The doses may consist of from a 
quarter of a grain to a grain every hour or two hours. Some writers 
also recommend very highly the use of mercurial inunction. Vogel 
(oj9. cit., p. 361) states that a mercurial treatment is decidedly effectual, 
and adds that the only two children he has seen recover from this dis- 
ease, were treated exclusively with mercury, internally and externally. 

Counter-irritants are useful as adjuvants to the more powerful remedies 
already indicated. During the first day or two they should consist 
chiefly of sinapisms and mustard poultices, applied from time to time 
to the trunk and extremities. Authorities differ somewhat as to the 
effect of blisters, and as to the time at which they ought to be applied. 
M. Yalleix {op. cit., t. ix, p. 187), opposes their employment in this 
aff'ection as often injurious and still more frequently useless. We think 
the advice given by Dr. Abercrombie, as to their employment, is prob- 
abl}^ the most prudent. This is, not to apply them in the early stage, 
but to wait until the active symptoms of the disease have been subdued. 
They may be applied to the head itself, to the nucha, or to the extremi- 
ties. We believe that we have seen them most useful when applied to 
the neck and inside of the calves of the legs. Nevertheless, there is 
high authority in favor of their good effects when applied upon the 
head itself. 

M. Rilliet {loc. cit.) recommends a vigorous revulsion upon the scalp 
when the disease has followed the suppression of an eruption. He pro- 
poses with this view the employment of pustulation by croton Oil, and 
relates a case of recovery which followed this treatment under a most 
unfavorable train of symptoms. To make use of it the head must be 



CEREBRAL CONGESTION. 515 

first shaved ; from fifteen to twenty' drops of the oil are then to be rubbed 
over the scalp with a glove four or six times a day. Before making 
the friction, the eyes of the patient must be covered with a band to 
prevent the introduction of any of the oil into them, as this would be 
apt to occasion severe ophthalmia. In the case reported by him, a con- 
siderable number of pustules were produced in twenty-four hours, and 
in a few more hours the eruption was general, so that the head was 
covered with a kind of cap of a fine yellow color. 



ARTICLE III. 

CEREBRAL CONGESTION. 

We believe, from our personal observation and from the evidence of 
several of the highest authorities on the diseases of children, that cere- 
bral congestion is of rare occurrence as an idiopathic and distinct affec- 
tion in early life. We think that the s^^'mptoms which are detailed in 
this article, and which are by several winters, and especially by Dr. 
West, attributed to congestion of the brain, are rather due in some cases 
to mere excitement and undue rapidity of the circulation, and in others 
to the irritation of the brain, caused by the circulation through it of a 
blood vitiated by the poison of some of the acute specific diseases. In 
other instances still, we think the attacks are more accurately included 
under the title of eclampsia. 

In support of these views we quote below the opinions of some of the 
authors referred to. MM. Rilliet and Barthez assert (lere edit., t. i, p. 
649) that they have found in children dying of different diseases, and 
who had presented no cerebral symptoms, congestion precisely similar 
to w^hat they found in others who had exhibited more or less danger- 
ous idiopathic or secondary nervous symptoms. " Some patients," they 
remark (Joe. cit., p. 650), "it is true, who presented us w^ith examples 
of cerebral hypersemia, had had well-marked nervous symptoms. Thus 
we have met with the anatomical characters of congestion in young- 
subjects who had perished with convulsions, in those whose sickness 
had been accompanied by violent delirium, and in others w4io, in the 
course of scarlet fever for instance, had been seized with nervous s^^mp- 
toms. But, on the other hand, we have met with a nearly equal num- 
ber of patients who had died under the same circumstances, but in 
whom the cineritious and medullary substances preserved their usual 
color, and the pia mater was not injected. What are we to conclude 
from these facts? Most assuredly that we ought not to attribute to 
cerebral hypersemia any considerable part in the production of the 
symptoms." At page 651 they say: "The most important practical 
point is in fact to determine whether it is possible to recognize cere- 



516 CEREBRAL CONGESTION. 

bral congestion in a child by special and characteristic symptoms, and 
whether we ought as a consequence to prescribe a particular form of 
treatment. We acknowledge, on our part, that we find it impossible 
to describe any symptoms peculiar to that condition, and consequently^ 
to formulate a treatment." In the article on convulsions (t. ii, p. 281), 
they state that in some of their patients they found no traces of con- 
gestion, and add that eclampsia is sometimes (a well-known fact) con- 
nected with an ausemic state of the brain. "What are we to conclude 
from these opposite facts, if it be not that congestion plays but a sec- 
ondary part in convulsions?" They coincide in opinion with the 
authors of the Compendium, who suppose that the congestion found in 
patients who have died with convulsive symptoms, is generally the 
effect and not the cause of the convulsions. They do not deny, how- 
ever, that a sudden congestion of the brain may produce a convulsive 
attack, and quote cases from other writers. 

We believe it to be a very common opinion in this country that most 
of the nervous symptoms (delirium, somnolence, coma, convulsions, &c.) 
which occur in the course of many of the diseases of childhood, depend 
chiefly upon a congested condition of the nervous centres, and many 
practitioners refer most of the cases of eclampsia of children to the same 
cause. We are glad, therefore, to call the attention of the profession 
to this point, and to place before it the opinions of some of the recent 
distinguished authorities in regard to it. 

The authors of the Bibliotheque du Med. Prat, are of opinion that it is 
very rare to meet with true pathological and idiopathic congestion of 
the brain, either in the first or second infancy (t. vi, p. 118). M. Bar- 
rier states that primary or secondary hypersemias are sometimes a 
cause of convulsions, and that such cases are the most dangerous of 
their kind. He also states that in rare instances congestion assumes a 
more menacing character, similar to that which is more frequently met 
with at an advanced age, meaning the apoplectic form. M. Yalleix 
asserts {op, cit., t. ix, p. 259) that "cerebral congestion is a disease 
almost unknown in infancy." 

M. Killiet, in the paper on simple meningitis quoted in the article 
on that disease, states, as his opinion, that the cases attended with 
dangerous cerebral symptoms, which resemble exactly those occur- 
ring at the commencement of meningeal inflammation, which termi- 
nate rapidly in death or recovery, and in which the only lesions found 
after death are congestion of the brain and its membranes, ought to be 
regarded as dependent upon congestion, though he thinks it difficult 
to determine positively whether they are in fact the result of that con- 
dition, or whether thej^ are not merely the forming stage of meningitis. 

Dr. Charles West, of London, whose publications upon the diseases of 
children are amongst the most valuable that the English press has 
afforded us, treats of congestion of the brain in children as a very im- 
portant and frequent condition of disease. We shall chiefly follow him 
in our remarks upon this subject, although we have no doubt, from our 
own observation and from the researches of the French observers above 



GENERAL REMARKS. 517 

quoted, that its importance has been much exaggerated, and that its 
real influence in the production of the symptoms generally ascribed to 
it is very imperfect!}' understood. 

Dr. West treats of congestion of the brain under two heads, as active 
or passive. By the former is meant the kind of congestion occurring 
under the influence of a cause which greatly increases the flow of blood 
to the head, and to this class belong, for instance, the head symptoms 
which often usher in the eruptive fevers; by the latter is understood 
the kind depending on an impediment to the reflux of blood from the 
brain, to which belong, for example, the convulsions which occur in a 
fit of hooping-cough. 

Active congestions may occur during the process of dentition, or 
may result from exposure to the sun, or from blows upon the head; 
passive congestion may be the result of a mechanical impediment to 
the return of blood from the brain, as the pressure of an enlarged thy- 
mus, or it may be the result of enlarged and tuberculous cervical or 
bronchial glands pressing upon the jugular veins, or of languid circula- 
tion depending upon want of pure air, or of nourishing and sufficient 
food. Dr. West states that intense cerebral congestion is not a very 
unusual consequence of the disturbance of the circulation at the outset 
of the eruptive fevers. He says that convulsions and apoplectic symp- 
toms sometimes come on suddenly in these cases, and may terminate 
fatally in less than twenty-four hours; after death "the brain is found 
loaded with blood, but all the other organs of the body are quite 
healthy." We would merely remark here, that it seems to us very 
doubtful whether the nervous symptoms just alluded to, ought not to 
be regarded as the result of the presence in the nervous centres of a 
diseased and vitiated blood, rather than of congestion. That conges- 
tion does not always produce them is shown by the statement of MM. 
Eilliet and Barthez (op. cit., t. ii, p. 620), in regard to the cerebral symp- 
toms of scarlet fever, "that a more or less marked sanguine congestion 
(of the cerebro-spinal apparatus) is the only alteration generally but not 
always found; and sometimes the congestion is not more marked than 
in other diseases in which there had been no cerebral symptoms." 
With these remarks we shall pass on to the consideration of the symp- 
toms generallj^ ascribed to congestion occurring under other circum- 
stances, as those taking place in the course of the eruptive fevers will 
be treated of under the head of those afl'ections. 

Dr. West states that cerebral congestion may come on suddenlj^ with 
very alarming symptoms, or it may be preceded for a few days by gen- 
eral uneasiness, by a disordered state of the bowels, generally but not 
always consisting of constipation, and by peevishness. " The head by 
degrees becomes hot, the child grows restless and fretful, and seems 
distressed by light or noise, or sudden motion, and children who are 
old enough sometimes complain of their head." Vomiting generally 
occurs repeatedly, sometimes before any other symptoms, and is a very 
important sign. The fever varies greatly as to its violence, though the 
pulse is usually much and permanently quickened, and if the skull be 



518 CEREBRAL CONGESTION. 

Still iinossified, the anterior fontanelle is either tense and prominent, or 
the brain is felt and seen to pulsate forcibly through it. The sleep is 
disturbed, the child often waking with a start, and there is often occa- 
sional twitching of the muscles of the face or the tendons of the wrist. 

The child, Dr. West remarks, may recover from these symptoms 
without any medical interference, or the case may become aggravated 
and terminate in acute hydrocephalus; or again, the congestion may 
increase and cause the following symptoms. Under the latter condi- 
tion, " the countenance becomes heavy and anxious, the indifference to 
surrounding objects increases, and the child lies in a state of torpor or 
drowsiness, from which, however, it can at first be roused to complete 
consciousness." The bowels generally continue constipated, and the 
vomiting seldom ceases, though it may be less frequent. The pulse is 
usually smaller than before, and often irregular in its frequency, though 
not intermittent. "An attack of convulsions sometimes marks the 
transition from the first to the second stage; or the child passes, with- 
out any apparent cause, from its previous torpor into a state of con- 
vulsions, which subsiding, leaves the torpor deeper than before. The 
fits return, and death may take place in one of them, or the torpor 
growing more profound after each convulsive seizure, the child at 
length dies comatose." 

This second stage is usually of short duration, as death generally 
occurs, unless relief be afl*orded by appropriate treatment, within forty- 
eight hours from the first fit, " though no graver lesion may be discov- 
ered afterwards than a gorged state of the vessels of the brain and its 
membranes, and perhaps a little clear fluid in the ventricles and below 
the arachnoid." Occasionall}^, however, recovery takes place, contrary 
to all expectation, after these symptoms have continued but slightly 
modified, for days or even weeks. 

Acute congestion is to be treated like simple meningitis, with blood- 
letting, cathartics, calomel, cold applications to the head, baths, revul- 
sives, low diet, and confinement to a cool, dark chamber. It is useless 
to repeat here, what has already been said in our remarks upon the 
treatment of meningitis. 

In passive congestion the treatment should consist, according to Dr. 
West, of careful local depletion, if the case will bear it, and in strict 
attention to the diet and state of the bowels. He recommends mercury 
and chalk, to correct the bowels when they are out of order. If the 
case be associated with diarrhoea and bad nutrition, he recommends 
that extract of bark, with a few drops of sal volatile, or of the com- 
pound tincture of bark, be given two or three times a day. Farina- 
ceous food, he remarks, is not usually well digested when nutrition is 
much impaired, and he recommends milk and water, or milk and water 
with light meat broths. 



CEREBRAL HEMORRHAGE. 519 

AETICLE lY. 

CEREBRAL HEMORRHAGE. 

We shall consider hemorrhage of the brain under two heads, that of 
the substance, and that of the membranes ; the former is usually desig- 
nated as cerebral, and the latter as meningeal apoplexy. Both these 
forms of hemorrhage are of rare occurrence in childhood compared 
with other diseases of the brain, and with their frequency during adult 
life and old age. Of the two kinds, that of the meninges is the most 
common. 

Definition; Frequency; Forms. — By cerebral apoplexy or hemor- 
rhage is understood an effusion of blood into the substance of the 
brain. By meningeal apoplexj^or hemorrhage is understood an effusion 
of blood between the dura mater and cranium, into the cavity of the 
arachnoid membrane, beneath the arachnoid, or in the meshes of 
the pia mater. Cerebral hemorrhage is a verj^ rare affection in child- 
hood. This is proved to be the case hy the facts that MM. Rilliet and 
Barthez met with only eight cases in their extensive experience, and 
that M. Barrier saw but one in 576 cases of disease of all kinds. Men- 
ingeal apoplexy is of more frequent occurrence, since MM. Rilliet and 
Barthez report eighteen cases. M. Barrier met with one case of this 
form in the 576 cases referred to. Dr. West (^London Med. Gaz.^ June 
18th, 1847, p. 1062) says he has only twice met with distinct extrava- 
sati(m of blood into the substance of the brain in children. 

Hemorrhage into the substance of the brain occurs in two different 
forms: one in which the effused blood is contained in a cavity caused 
by a laceration of the tissue of the organ, and designated apoplexy in 
a cavity ; and the other in w^hich the blood is effused in a multitude of 
little points of different sizes, and designated capillary apoplexy. 

In meningeal hemorrhage the blood may, as we have stated, be effused 
between the dura mater and the bone. This form, however, is very 
rare, so rare, indeed, that several writers deny its existence. It is 
proved, however, to have occurred, by a case reported by MM. Rilliet 
and Barthez, which is the only one they have met with. In by far the 
most common form of the disease, the blood escapes into the cavity of 
the arachnoid membrane. Of this form the authors just quoted report 
17 cases, while, according to the authors of the Blbliotheque du Med. 
Prat. (t. vi, p. 193), the effusion always occurs in this situation. That 
this is not invariably correct, however, is proved b}'' the case of effu- 
sion exterior to the dura mater already referred to, and by the fact 
that it sometimes takes place beneath or in the meshes of the pia 
mater. The latter class of cases is very rare, however, in proportion 
to those in which the hemorrhage occurs within the cavit}^ of the arach- 
noid. MM. Rilliet and Barthez did not themselves meet with a single 
instance of that kind, but they quote two from other writers ; and M. 



520 CEREBRAL HEMORRHAGE. 

Yalleix refers to a meniDir by M. Prus, in which others are given. It 
appears, therefore, that in the great majority of instances, the effusion 
takes place within the cavity of the arachnoid membrane. 

Causes. — The causes of cerebral hemorrhage are very obscure, so 
much so, indeed, that some writers have not attempted to ai^certain 
them. They appear to be the same in both forms of the affection. 
Amongst the ascribed causes are the sudden disappearance of erup- 
tions of the scalp, observed in two cases by MM. Eilliet and Barthez, 
in one of which this effect is stated to have been produced suddenly 
by medical treatment, while in the other it followed the application of 
poultices to a favous eruption upon the same part. This cause must, 
however, it appears to us, be regarded as purely illusory. The disease 
is stated by M. Legendre to have followed in one case a violent fit of 
anger. It is said also to have been produced by various causes which 
acted as impediments to the circulation. The obstacle may be situated 
within or exterior, to the cranium. To the first class belong eases in 
which the sinuses and large venous trunks of the head have been found 
obstructed by coagula of blood, or by the pressure of tumors, generally 
of a tubercular nature ; to the latter, those in which there is intense 
engorgement of the superior cava produced, as in prolonged paroxysms 
of hooping-cough, or in obstructive cardiac disease, or where there is 
compression of this vessel by enlarged and tubercular bronchial glands. 
Another cause is thought to be the existence of confirmed cachexia and 
general debility from any diseased condition whatever, in which the 
blood having become thin and lost its plasticity, escapes from the 
vessels with great facility. This last condition is one which almost 
always exists in connection with the causes cited as acting through 
the agency of obstruction to the circulation, and tends of course to aug- 
ment their dangerous effects. Occasionally, also, aneurisms of the cere- 
bral arteries, especially of the middle cerebrals, occur at an early age 
(several cases are on record at the age of 14 years), and by the rupture 
of the sac give rise to excessive and rapidly fatal cerebral hemorrhage. 

We have met with one case of extensive hemorrhage into the left 
corpus striatum and adjoining tissue in a boy of 13, evidently connected 
with advanced granular degeneration of the kidneys, resulting from a 
previous attack of scarlatina. 

In some instances the hemorrhage occurs in the healthiest and most 
vigorous constitutions, and cannot be accounted for in any way. 

It appears that meningeal apoplexy is most frequently met with in 
ver}^ young children, according to MM. Eilliet and Barthez, between 
the ages of one and two and a half years, whilst M. Legendre did not 
meet with a single case after three years of age in 248 autopsies. 
Cerebral and ventricular hemorrhage, on the contrary, are much more 
common after three years of age than before, which is just the reverse 
of the law in regard to meningeal effusion. 

Anatomical Lesions. — The description of the lesions of hemorrhao-e 
into the substance of the brain need not detain us long, for they are 
much the same as those observed in the adult. When the blood is 



ANATOMICAL LESIONS. 521 

effused into cavities (apoplexy in cavities), the latter are usually small 
in size, seldom exceeding from one to two-thirds of an inch in diam- 
eter, though in rare cases they have been found much larger. The 
cavity is formed by a laceration of the substance of the brain, and is 
filled with soft, dark coagula, or sometimes with fluid blood; the walls 
of the cavity consist sometimes of the substance of the brain, which 
may be of a rosy color and natural consistence, or ^^ellowish and soft- 
ened, while in other instances they are formed of more or less numer- 
ous points of capillary apoplexy. The capillary form of effusion occurs 
in the shape of a number of points, scarcely so large as the head of a 
small pin, and of a dark or brownish color, which contrasts strongly 
with that of the cerebral tissue. These points evidently consist of true 
coagula, which are sometimes surrounded by small yellowish areohie. 
The substance of the brain around the effusion is either white, firm, 
and perfectly health}^, or softened, and of a whitish, reddish, or yellow- 
ish color. The capillary effusions are generally limited within a space 
of from a third of an inch to an inch and a half in size, but they have 
been found scattered over a large portion of the hemispheres. 

Both forms of hemorrhage are much more common in the cerebrum 
than cerebellum, and occur more frequently on the left than right side. 
In addition to the sanguine effusion there is generally considerable con- 
gestion of the pia mater, of the venous sinuses, or of the substance of 
the brain itself. 

In describing the lesions of meningeal apoplex}^, we shall confine our 
remarks to the effusion which occurs into the cavity of the arachnoid, 
this being, as we have already remarked, by far the most frequent form 
of the disease. 

The appearances presented by the cavity of the arachnoid into which 
the effusion has taken place vary greatly in different cases, according 
to the age of the child, the quantity of the hemorrhage, and the period 
of time Avhich may have elapsed between the accident and the death 
of the patient. It is very uncommon to find pure liquid blood, though 
this has been met with. In most instances, there is a bloody serum 
mixed with thin, reddish coagula, contained in a soft and very delicate 
membrane lining the internal surface of the arachnoid. Sometimes the 
effusion is thin, limpid, and more or less yellowish in color, while at 
other times it is thick and brownish, or chocolate-colored. In some 
rare cases it is perfectly transparent and colorless. The fluid, in what- 
ever state it exists, appears to be the result of transformations under- 
gone by the effused blood. The solid portion of the blood or clot is 
found either in the condition of more or less recent coagula, or changed 
into false membranes, which sometimes resemble very closely the 
arachnoid itself, and sometimes a true fibrous membrane. The coag- 
ula- are found in the form of thin membranes, varying between one or 
two lines in thickness, and an inch and a half to two inches in size. 
They are thickest generally in the centre, where they measure be- 
tween a fifth of a line and two lines, and are brownish or greenish in 
color, and of variable consistence, according to their age. These coag- 



522 CEREBRAL HEMORRHAGE. 

iila may exist upon any portion of the brain, but, according to MM. 
Rilliet and Bartbez, are most frequently met with upon its convex 
surface. 

The coagula just referred to undergo in some instances a curious 
change, of which we shall give a short description. In the course of 
time, the fibrinous portions of the blood are deposited upon the internal 
surfaces of the cavity of the arachnoid, in the form of a new membrane. 
When death occurs soon after the onset of the attack, the parietal layer 
of the arachnoid is found to be completely lined with this membrani- 
form production, whilst the visceral or cerebral layer is covered by it 
only in certain points. When the case has lasted a longer time, on 
the contrary, the visceral as well as the parietal layer of the arachnoid 
may be covered with the new production, and when this happens there 
is formed a true sac or cyst, destitute of opening, which lines the whole 
interior of the arachnoid, and contains within its cavity bloody serum 
and coagula. At first this new membrane is reddish in color, elastic, 
and of a stronger texture than might be suj^posed from its apparent 
thinness and softness. Its thickness is generally about a tenth of a 
line. At a later period the walls of the cj^st become so thin and trans- 
parent that they have been mistaken for the arachnoid itself. They 
diff'er, however, from the latter in being rather less transparent and 
thin, and particularly in the circumstance of presenting numerous vascu- 
lar arborizations. When death occurs at this stage, which M. Legendre 
(whose description we chiefly follow) calls the second period, or that of 
complete organization of the cyst, the external surface of the latter is 
found to adhere intimately to the parietal portion of the arachnoid 
membrane, by very delicate cellular tissue, though not with so much 
force but that it may be detached by traction. The internal portion of 
the new membrane, on the contrary, which is lubricated by the serosity 
of the arachnoid tissue, is very slightly adherent to the layer of that 
membrane covering the brain. 

So long as the cyst formed by the new membrane, or, as it is called 
by MM. Eilliet and Barthez, the pseudo-arachnoid membrane, contains 
an amount of fluid sufficient to keep its surfaces separated, its cavity 
is single. When, on the contrarj^, the walls of the cyst have come into 
contact, either because of the partial absorption of the contained fluid, 
or because the fluid has accumulated at the lowest points, or wherever 
there is the least resistance, the cavity becomes multilocular in conse- 
quence of the cohesion of its walls at certain points. 

The size of the cyst varies exceedingly. Sometimes it covers the 
greater part of the convex surface of one hemisphere, sometimes the 
whole, while in other instances it extends to the base, forming in that 
case a nearly complete shell for the whole brain. The quantity of 
fluid varies in different cases. Sometimes it amounts only to a few 
large spoonfuls; in others, to one or two, or eight or nine ounces: in 
one case observed by MM. Eilliet and Barthez there was upwards of a 
pint on each side, or more than a quart in all. In most instances the 
hemorrhage occurs into both halves of the arachnoid membrane, so 



SYMPTOMS. 523 

that there is a cyst for each hemisphere. More rarely it occurs only 
on one side. 

In the second stage, and Tvhen the effusion is very large, which 
rarely happens except in young children, and prior to ossification of 
the fontanelles or sutures, the lesion constitutes a form of chronic ex- 
ternal hydrocephalus, and the sj-mptoms are such as will be detailed 
under the head of this latter disease. The vault of the cranium is en- 
larged by the unnatural prominence of the frontal and parietal bones; 
the sutures are more open than usual, and the anterior fontanelle is 
distended and protuberant. When the effusion occurs thus early in 
life, before complete ossification of the skull, the brain does not appear 
compressed or flattened, as it does when the disease occurs at a later 
period. 

The visceral portion of the arachnoid is often thickened, opaque, and 
more resisting than natural. The pia mater is frequently infiltrated 
with a good deal of serosity, which sometimes has a gelatinous appear- 
ance. When death has occurred in the first stage of the disease, the 
brain usually presents signs of hypersemia. The veins on the surface 
of the hemispheres are enlarged, the cortical substance is of a bright 
rose-gray color, and the medullary portion is dotted over with drops 
of blood. Sometimes the cellular substance beneath the arachnoid is 
slightl^^ infiltrated with serosity, at other times not. The ventricles 
contain a xery small quantity of fluid. 

The exact anatomical cause of cerebral hemorrhage in children is 
still subject to some doubt. It appears probable that it usually results 
from intense determination of blood to the head, or from extreme pas- 
sive congestion, which lead to the rupture of vessels so minute as to 
escape notice, or possibly in some cases to the transudation of blood 
through the capillary walls without actual rupture. We are not aware 
that any careful microscopic examination has yet been made of the 
condition of the walls of the vessels in such cases. In some rare in- 
stances, however, as in one witnessed by M. Legendre, the effusion is 
the result of the rupture of a vessel of some size. In the case observed 
by him, death took place in twelve hours from the attack, and the left 
hemisphere was found covered with a layer of coagulated blood, which 
had escaped from a ruptured vein. (Biblioth. du Med. Frat., t. vi, p. 
192.) 

Symptoms ; Duration. — The symptoms of liemorrliage into the substance 
of the brain in the child are, as a general rule, extremely obscure and 
uncertain, though in some few cases that have been observed, they 
were as characteristic as those which occur in adults. In obscure 
cases, the chief symptoms that have been noticed were restlessness, 
delirium, headache, violent fever, grinding of the teeth, and, after a 
time, complete abolition of the intelligence, fixity of tiie eyes, invari- 
able dilatation of the pupils, stertorous respiration, and general insen- 
sibility. Of three cases reported by M. Yalleix (Clinique des Mai. des 
Enf.)^ the nature of the disorder was easily diagnosticated in one by 
the existence of complete hemiplegia, while in the two others the only 



524 CEREBEAL HEMORRHAGE. 

marked symptom was entire immobilitj^ The only certain symptom 
of the disease, therefore, would be a sudden attack of hemiplegia, either 
as the primary sj^mptora, or following coma or convulsions, and histing 
for at least several days. An attack of general paralysis would not be 
by any means so certain, as this may exist in several other diseases of 
childhood. 

In a case which came under our charge, we believe the attack to 
have been one of apoplexy of this kind. 

Case. — A girl, two years and a half old, apparently in the enjoyment of excellent 
health, was suddenlj^, and without ascertainable cause, attacked with violent general 
convulsions and entire insensibility, which lasted with very slight remissions of the 
convulsive movements, but without any return of consciousness, for twelve hours. 
At the end of that time the convulsions ceased entirely, and she very soon regained 
her consciousness, remaining merely peevish and languid. She was, however, com- 
pletely hemiplegic on the left side, so that she could neither rise in bed, nor turn 
towards the right side. The paralysis diminished rapidly, but regularly, so that at 
the end of three days she could sit up in bed, and in a few weeks was perfectly well. 
This child remained well, with the exception of rather unusual excitability, and some 
peevishness of temper, for three years, when she died of scarlet fever. 'No autopsy 
could be made. 

The obscurity w^hich exists in these cases will be clearlj^ understood 
by any one who will read two examples given by Dr. West (loc. cit., p. 
1062). 

With a short quotation from the work of MM. Eilliet and Barthez, 
we shall pass on to the subject of meningeal apoplexy. These authors 
remark (op. cit., t. ii, p. 54), in speaking of this affection, that " cerebral 
symptoms have been observed to exist, but of so unusual a character, 
and so different from what have been assigned by writers to apoplexy, 
that they could not lead to a diagnosis of the disease." 

We shall describe the symptoms of the meningeal form of hemorrhage 
under two heads: first, as they present themselves in the acute, and, 
second, as they occur in the chronic or second stage of the affection. 

Unfortunately the symptoms of the acute or first stage are not much 
more certain and distinct than those of cerebral hemorrhage. The 
disease may begin with fever and some convulsive movements, or, as 
happened in a case reported by M. Valleix, with violent general con- 
vulsions. Yomiting sometimes occurs at the beginning, but is usually 
very slight. It is difficult to know whether headache exists or not at 
the early age at wiiich this disease commonly occurs. The convulsive 
movements generally affect particularly the eyes, and are followed by 
some degree of strabismus. The appetite is lost from the first; the 
thirst is moderate ; there is no constipation. Soon after the symptoms 
just described, appear permanent contractions of the hands and feet, 
which are followed by attacks of tonic or clonic convulsions, during 
which sensibility and intelligence are abolished. Between the attacks 
of convulsions there is somnolence, which, though slight at first, be- 
comes more marked as the case goes on. The attacks of convulsion 
become more and more frequent as the case progresses, until at last 



SYMPTOMS OF THE MENINGEAL FORM. 525 

they are neai'lj constant. The tonic convulsions affect the limbs and 
trunk both, but particularly the former, whilst the clonic spasms occupy 
sometimes one side of the body, sometimes the upper extremity alone, 
and at other times the whole body, but even then are usually stronger 
on one side than on the other. Paralysis is rarely noticed in the dis- 
ease ; it occurred only in one out of nine cases observed by M. Legen- 
dre, and in one out of seventeen observed by MM. Eilliet and Barthez. 

Dr. West remarks (p. 1061) : " The absence of paralytic symptoms, 
however, is not the sole cause of the obscurity of these cases, but the 
indications of cerebral disturbance, by which they are attended, vary 
greatly in kind as in degree. The sudden occurrence of violent con- 
vulsions and their frequent return, alternating with spasmodic contrac- 
tion of the fingers and toes in the intervals, appear to be the most 
frequent indications of the effusion of blood upon the surface of the 
brain. I need not say, however, that such symptoms, taken alone, 
would by no means justify you in inferring that an effusion had taken 
jDlace." Dr. West adverts particularly to the fact that apoplexy in the 
child is especially apt to occur in those who are weakly and feeble, and 
gives to this form of the disease the appellation of the cachectic form 
of cerebral hemorrhage. 

The chronic form presents most of the symptoms which exist in ac- 
quired chronic hydrocephalus from serous effusion into the ventricles. 
The cranium is very large in proportion to the face ; the sutures are not 
ossified; there is strabismus, with dilatation of the pupils; the sense of 
sight is generally but not always retained ; the face loses its expres- 
sion ; if the child was old enough at the moment of the attack to show 
signs of intelligence, the latter are found to diminish rather than in- 
crease, and sometimes they are lost entirely, as the size of the head 
augments ; and the child is apt to utter loud cries, particularly during 
the night. The cutaneous sensibility is in general neither lost nor 
diminished. The power of motion usually remains, though it was en- 
tirely lost in one case. The appetite and thirst persist. 

The duration of cerebral apoplexy is very irregular. In one case 
quoted by MM. Rilliet and Barthez, it was a quarter of an hour; in 
another, an hour; in a third, forty-eight daj^s ; and in one reported by 
M. Yaileix, in a very young infant, recovery was nearly perfect in a 
little less than two months, when the child was seized with pneumonia 
and died. 

The duration of meningeal apoplexy is also irregular. According to 
M. Legendre, all the recent cases seen by him in the Children's Hos- 
pital, died in from eight to twelve days, apparently rather from inter- 
current diseases than from the primary affection itself, whilst cases 
occurring in subjects placed in better hygienic conditions, and not at- 
tacked with intercurrent affections, passed into the second or hydro- 
cephalic stage of the disease. The second stage lasted, according to 
the same author, in the four cases which he witnessed, from eight to 
thirty months, and then death was the result, not of cerebral symp- 
toms, but of complications affecting the thoracic organs. 



526 CEREBRAL HEMORRHAGE. 

Diagnosis. — The diagnosis of cerebral hemorrhage is, as we have 
alreadj^ stated, very difficult, unless hemiplegia exist. When the case 
commences, as it often does, with convulsions or with inflammatory 
symptoms, it is often impossible to distinguish it from acute or tuber- 
cular disease of the brain. 

The diagnosis of meningeal hemorrhage is also very often extremely 
difficult. Kot unfrequently it occurs in the course of other diseases, 
and is then entirely latent. In acute, primary cases, the most impor- 
tant and distinctive symptoms are the early age of the subjects, between 
one and three years generally; the violent fever from the commence- 
ment, marked by full, frequent, and regular pulse ; the absence of con- 
stipation ; the frequency of the convulsive attacks, and particularly the 
permanent contraction with rigidity of the feet and hands. 

The diagnosis between the form of hydrocephalus which follows 
meningeal apoplexy, and ventricular serous hydrocephalus, is exceed- 
ingly obscure. The only circumstances which seem to have any real 
value are the acute commencement of the disease with the symptoms 
above detailed, and the early age of the patient. MM. Eilliet and Bar- 
thez state that they have never known a child of two years old, or 
younger, to die of ventricular serous hydrocephalus from tumors, 
whether tubercular or not, of the brain; in all such cases the effusion 
has been the result of a hemorrhage. 

Prognosis. — The prognosis of both forms of the disease is very grave. 
It is imj^ossible, however, to ascertain the prognosis with any certainty, 
so long as the symptomatology of the two affections is so obscure as 
we have found it to be. That cerebral hemorrhage is susceptible of 
cure, however, is proved by the case reported by M. Yalleix, already 
referred to, in which the child had nearly recovered, when it was 
seized with another disease which destroyed it. Recovery from 
meningeal apoplexy is certainly extremely rare; we believe, however, 
that Ave have met with one case in which this affection terminated 
favorably. 

Treatment. — The treatment must depend on the diagnosis and the 
special character of the symptoms in each case. In a sudden and 
severe attack, occurring in a strong and hearty child, in which the 
symptoms of congestion of the brain are strongly marked, and where 
we are notj^et certain that actual hemorrhage has taken place, we should 
immediately resort to a general or local bloodletting. It was formerly 
customary to employ venesection in all such cases, but we believe that 
equal relief can be obtained b}^ freely cupping or leeching the back of 
the neck. 

When, however, we have every reason to believe that blood has been 
effused either in the membranes or into the substance of the brain, it is 
evident that bloodletting can produce but little effect, and that only in 
reducing the general fulness of the cerebral vessels. In such cases we 
should certainly limit ourselves to the application of a few cut cups or 
leeches to the nucha. 

It must further be remarked, however, that in many cases of cerebral 



TREATMENT. 527 

or meningeal apoplexy, depletion in any form is entirely contraindi- 
cated ; since, as has already been stated, the effusion of blood occurs 
frequently in feeble and weakly children, and either in the course of 
some acute or chronic disease, or as a consequence of previous diseases 
which have exhausted the forces of the constitution and induced a state 
of dyscrasia and diffluence of the blood. In such cases as these we 
must depend upon the use of rest, cold applications, purgatives^ and 
counter-irritants as recommended below. 

Cold applications should be immediately made to the head, either by 
wet cloths, the ice bladder, or by cold affusion. At the same time, or 
as early as possible after the invasion, a dose of some purgative medi- 
cine must be given. The best is calomel, either alone or combined 
with jalap or rhubarb. If given alone, it ought to be followed in an 
hour or two by castor oil, infusion of senna and manna, salts, mag- 
nesia, or some active cathartic. When the symptoms are very urgent, 
it is well to open the bowels still more speedily by a purgative enema. 

Counter-irritants are always useful adjuvants to the remedies already 
mentioned. They should consist at first of mustard plasters applied to 
the extremities, and shifted from place to place. When the symptoms 
do not yield after proper depletion and the use of sinapisms for some 
hours, it is well to apply blisters to the calves of the legs, and to the 
nape of the neck. 

The diet must be very strict, and should consist only of barley or 
arrowroot water, for a few days. 

The temperature of the room should be kept cool; and the child 
should be placed with the head and trunk somewhat elevated, and 
kept profoundly quiet. 

For the paralysis which follows apoplexy in children, we believe that 
the most important, and indeed the only treatment necessary, is atten- 
tion to the general health of the patient, in order to give to nature time 
and opportunity to eflTect the absorption of the clot which has. been 
thrown out into the substance of the brain, or into the cavity of the 
arachnoid membrane. This process may, however, be aided and hast- 
ened by the prolonged administration of iodide of potassium with the 
iodide of iron. In cases of meningeal apoplexy, when the disease as- 
sumes the chronic form, occasioning the kind of hydrocephalus we 
have described, there is little more to be done than to attend to the 
general health of the child, and to endeavor to promote absorption of 
the fluid by the internal administration of diuretics, and the prepara- 
tions of iodine. It has been proposed also to get rid of the fluid by 
tapping, as has been done in congenital h^^drocephalus, and it is indeed 
in cases of the form we are now considering, when the fluid is entirely 
external to the brain, and where no malformation or organic disease of 
the brain exists, that this operation has been found most successful. 
(See treatment of chronic hydrocephalus.) 



528 CHRONIC HYDROCEPHALUS. 

AETICLE Y. 

CHRONIC HYDROCEPHALUS. 

This term is applied to an affection characterized by an excessive 
accumulation of serous fluid, either within the ventricles of the brain 
or the sac of the arachnoid. 

The names internal and external have also been applied to it, in ac- 
cordance with the position of the fluid : the former being given to 
those cases where the ventricles are the seat of the morbid collection, 
and the latter indicating that the fluid has accumulated in the cavity 
of the arachnoid and consequently surrounds the exterior of the brain. 
Chronic hydrocephalus may either be congenital or acquired^ the latter 
variety presenting the most interest in a practical point of view, since 
congenital hydrocephalus is usually associated with some malforma- 
tion of the brain which renders extra-uterine life almost impossible. 

In either form it is a rare disease in Philadelphia, so that but com- 
paratively few opportunities are afforded for studying either its pa- 
thology or treatment. 

Morbid Appearances. — There are indeed few diseases in which it is 
of more importance to correctly establish the exact nature of the mor- 
bid process and the resulting lesions, since, as we shall see in a later 
part of this discussion, questions of the utmost practical value hinge 
upon the determination. 

Internal Hydrocephalus. — In this condition the amount of fluid is often 
very large, and varies from half a pint or a pint, to even as much as a 
gallon. Trousseau mentions a case where the flui.d weighed 30 pounds, 
and Frank one in which it weighed 50 pounds. The formation of this 
accumulation being gradual, the cavities of the brain accommodate 
themselves to it, the ventricles become distended, and the communica- 
tions between their cavities are all enlarged; and occasionally the sep- 
tum lucidum is perforated. This distension is usually most marked in 
the lateral ventricles. The hemispheres of the brain yield to the 
pressure of the increasing collection in the ventricles; their convolu- 
tions are unfolded and flattened, so that the interval between them is 
only marked by a sinuous shallow groove, and the hemispheres are so 
thinned out as to form a layer not exceeding a few lines in thickness. 
It is not unusual, however, even when the distension of the brain has 
proceeded to this extreme degree, to be able to trace the cineritious 
and white layers, preserving their normal relations. The consistence 
of the expanded brain-substance varies in different cases; usually, how- 
ever, it remains normal, or is even increased, though in some cases it 
has been found so soft as to tear upon the slightest traction. The 
structures at the base of the brain present the same changes in con- 
sistence. 

One of the most important questions in this relation, as bearing upon 



ANATOMICAL APPEARANCES. 529 

the causation of the affection, concerns the condition of the lining mem- 
brane of the ventricles. 

The analogy of all other serous membranes would lead us to infer 
that in those cases -where no mechanical obstruction to the circulation 
exists, such as a tubercular tumor pressing upon the sinuses of the 
brain, we should look for the cause of the serous accumulation in a 
morbid state of the lining membrane of the ventricles. This view is 
fully confirmed by the study of fatal cases of internal hydrocephalus, 
since in many cases this membrane is found much thickened, and 
either softened or roughened and granular. The granular condition of 
the membrane presents many degrees: in some cases it is merely a 
slight irregularity of the surface, while in others there is an uneven- 
ness as marked as that of shagreen, or even a formation of granules, 
which, at times, measure one-third of an inch in diameter, or even be- 
come distinctly pedunculated. 

Occasionally, a false membrane is found lining one or both ventricles, 
as the result of the chronic inflammation of the lining membrane of 
these cavities. 

Even when the symptoms of hydrocephalus have not appeared until 
some time after birth, the brain may be found to present positive evi- 
dences of congenital malformation, in the retarded development of some 
of the structures at its base. 

The veins of Galen and sinuses of the dura mater are usually found 
in a healthy state, with their calibres quite free ; a fact which is of im- 
portance in considering the mode of production of internal hydro- 
cephalus. 

In external hydrocephalus, the collection of fluid occurs in the sac of 
the arachnoid, or in a pseudo-cyst resulting from the transformation of 
a blood-clot, as described in our remarks on meningeal apoplexy: the 
brain is separated from the cranial vault and compressed against the 
base of the skull, as the lung is forced back against the spinal column 
by the fluid of hydrothorax. 

The superior cerebral veins, passing from the surface of the brain to 
the longitudinal sinus, traverse the fluid, and at times are so much 
stretched as to raise the surface of the brain into points. 

Excepting in cases, however, where the disease is congenital and 
coincident with some original malformation of the brain, there is no 
absolute diminution in the size of this organ. 

The character of the fluid varies considerably in difl'erent cases, and 
probably depends to a great extent upon the cause. 

In an analysis by Spengler of the fluid evacuated in a case of hj^dro- 
cephalus by puncture, the fluid was clear and colorless ; specific gravity 
1010, of acid reaction, and contained no albumen. It also contained 
chlorides and phosphates of soda and potassa, but no sulphates. It ap- 
pears, therefore, in such cases as this, that the fluid is not the result of 
inflammation, but rather due to a passive dropsy. It is, we believe, 
especially in cases of external hydrocephalus, where the fluid results 

34 



530 CHRONIC HYDROCEPHALUS. 

from the transformation of a sanguineous effusion, that it possesses these 
characters. 

On the other hand, the fluid frequently contains a large amount of 
organic matter, and closely resembles the effusion in pleurisy or peri- 
carditis. Thus, in a case reported by Battersby, which was tapped 
eight times, the fluid always contained varying, and sometimes very 
large, proportions of albumen. 

Causes of Internal Mydrocephalus. — The opinions of the highest au- 
thorities and most experienced observers still differ widely upon this 
important point. 

We have alluded to the fact that not unfrequently the brain is found 
to present evidences of congenital malformation, and this fact has led 
to the opinion that internal hydrocephalus is almost invariably the effect 
of arrested development of the brain. 

Eilliet and Barthez place the effusion in this affection in the class of 
passive dropsies, and express their belief that most frequently the cause 
of internal hydrocephalus is to be found in compression of the veins of 
Galen or ventricular veins, caused by the development of a tumor in 
the cranial cavity, and usually in the lobes of the cerebrum. 

The unfavorable influence which either of these views would have 
upon the prognosis and treatment of this disease, is of course evident. 

On the other hand, however, the opinion is advanced that the start- 
ing-point of internal hydrocephalus is, in fact, a morbid condition of the 
lining membrane of the ventricles. 

We have briefly described the appearances of this membrane which 
have now been observed in numerous well-authenticated cases of inter- 
nal hydrocephalus, and which plainly indicate the pre-existence of a 
chronic inflammation, so that we are led to believe that in a certain 
number of cases, at least, the effusion is due to a slow inflammatory 
action in the lining membrane of the ventricles. Those cases in which 
these appearances have been found associated with retarded develop- 
ment of the brain, may be readilj^ explained upon the supposition that 
the inflammation has been excited at a more or less advanced period 
of intra-uterine life, and that the resuUing effusion has so compressed 
the structures at the base of the brain as to prevent their normal de- 
velopment. We may add that many eminent authorities, as Trousseau, 
now adhere to this view. 

In cases, however, where the effusion into the ventricles depends upon 
the development of a tumor in the cranial cavitj", the growth will 
usually be found to occupy the cerebral lobes in such a manner as to 
compress the veins of Galen, which pass along the under surface of the 
corpus callosum, and are indeed the only true ventricular veins. 

The causes of external hydrocephalus are perhaps less obscure and 
uncertain than those of the internal form. 

In some cases, the effusion in the sac of the arachnoid is evidently 
due to a rupture of some portion of a brain distended by accumulation 
of fluid in the ventricles, and hence is merely a sequel of internal hydro- 
cephalus. 



SYMPTOMS. 531 

According to the able investigatioDS of Legendre, and Eilliet and 
Barthez, one of the most frequent causes of external hydrocephalus is 
hemorrhage into the arachnoid space; the effused blood undergoing 
changes which result in the presence of large quantities of clear fluid, 
as described at length in our remarks on meningeal apoplexy. We have 
alluded to the fact that in many cases of external hydrocephalus the 
diminution in size of the brain is comparative rather than real; but 
there are instances where this form of the disease is found associated 
with malformation of the brain, which appears as a small, misshapen 
mass, pressed against the anterior part of the base of the skull. In 
such cases, it appears as though the fluid were poured out to fill up the 
vacuum between the skull and atrophied brain. It is also possible that 
these conditions may be produced by the occurrence of hemorrhage 
into the arachnoid space during intra-uterine life, and before the brain 
bad attained its normal development. 

Sy3IPtoms; Physical Appearance. — The unusual size of the head is 
one of the most striking symptoms of hydrocej^halus. In many cases 
associated with atrophy or retarded development of the bones of the 
face and the rest of the body, this enlargement appears even more 
monstrous than it in reality is. The diameters of the cranium are, 
however, very much enlarged; cases being on record in which at the 
age of a few weeks the circumference of the head has been twenty-three 
inches, or even more. 

The increase in the size of the head is not, however, invariably the 
earliest sign of the disease, being frequently preceded by marked 
symptoms of nervous disturbance, or of impaired nutrition. 

The bones of the cranial vault which contribute to this enlargement 
are the frontal, the parietals, the occipital, and the squamous portions 
of the temporals. When the disease makes its appearance before the 
ossification of the sutures and fontanelles has been completed, the grad- 
ual increase of the fluid separates these bones more and more widely. 
The occipital bone thus is pushed backwards, the parietals outwards 
and backwards, the frontal upwards and forwards. The increase in 
the size of the head is thus effected by the widening of the sagittal and 
coronal sutures, and by enlargement of the anterior fbntanelle. 

The displacement of the frontal bone gives rise to a marked promi- 
nence of the forehead, which overhangs the diminutive features: while 
at the same time the pressure of the fluid depresses its orbital plate 
into an oblique position, contracts the orbital space, and gives rise to 
the characteristic appearance of the eye, the globe being prominent but 
directed downwards so as to be buried beneath the lower eyelid, which 
conceals almost the entire cornea. 

The membrane which covers in the enlarged sutures is often dis- 
tended and prominent, or remains on the normal level. A distinct 
sense of fluctuation is readily obtained by palpating one of these spaces, 
and in some cases, principally in young infants, and where the collec- 
tion is very large, the head is absolutel^^ translucent. When life is pro- 
longed, and the disease arrested, the ossification of the cranial vault is 



632 CHRONIC HYDROCEPHALUS. 

effected by the development of oumerous supernumerary bones, or ossa 
triquetra, in the membranous spaces. These little bones are consequently 
found in the largest numbers in the coronal and sagittal sutures, where 
the deficiency is greatest and most wide. When, on the other hand, 
the disease does not begin until the sutures have united and the fonta- 
nelles ossified, it is rare for the head to attain any very large size. In 
a few cases, however, occurring in children of even nine years of age, 
the sutures have reopened under the continuous pressure, and the 
bones have been found separated as much as half an inch. 

More usually, however, in such cases, the pressure seems to expend 
itself in thinning the cranial bones, which become reduced to mere 
shells of light, fragile compact bone. Occasionally, so far from induc- 
ing thinning of the bones, actual h^^pertrophy occurs, and the bones of 
the cranial vault acquire an unusual thickness, and at the same time 
are dense and indurated. 

The early symptoms of the disease vary much. When it is congen- 
ital, there are nearly always evidences of cerebral disturbance either 
from the date of birth, or appearing within a few days. These symp- 
toms are occasionally slight, consisting merely in an unnatural expres- 
sion, with oscillation of the eyes or strabismus : or, on the other hand, 
there may be attacks of convulsions frequently repeated. 

These symptoms speedily become associated with enlargement of the 
head and the characteristic alteration of physiognomy. When the dis- 
ease is strictly acquired, the early symptoms are even more varied. 
In one set of cases they are those of hemorrhage into the arachnoid; 
in another the evidences of inflammation of the serous lining of the 
ventricles, of more or less acute character, are present; whilst in nu- 
merous cases the only symptoms which precede the enlargement of the 
head are those of failing nutrition. 

Usually the aspect of children suffering with this affection is tran- 
quil, or they may even present a certain unnatural gravity and apathy 
of expression. 

Cerebral Symptoms. — At times the intelligence of the child, though 
perhaps poorly developed, remains intact, and there is no marked cere- 
bral disturbance. 

In other cases, however, the advance of the disease is attended with 
a gradual failure of the intelligence, and impairment of the special 
senses, and especially of vision. 

In addition to the displacement of the globes of the eyes and altera- 
tions in the pupils already mentioned, the accumulation of fluid rapidly 
causes obstruction to the return of venous blood throuo-h the sinuses, 
80 that even at an early stage, ophthalmoscopic examination shows 
marked changes in the fundus of the eyes. These consist in increase 
in the number and size of the veins of the retina, with later serous in- 
filtration or even atrophy of the optic papilla. 

The nervous symptoms are at times much more marked; and there 
may be frequently recurring convulsive attacks, or, as West mentions 



DIAGNOSIS. 533 

having seen in several cases, spasmodic attacks of difficult breathing, 
Tvith a crowing sound in inspiration (larj^ngismus stridulus). 

According to Eiliiet and Barthez, the common sensibility of the sur- 
face is often impaired; and there may be more or less complete paraly- 
sis, or contraction with rigidity of the extremities. 

It is, of course, difficult to estimate the amount of suffering experi- 
enced by the little patients; ordinarily it does not appear great, and 
indeed in some cases it has seemed chiefly due to the opposition offered 
by the cranial walls to the distension of" the head. 

In one case of MM. Eilliet and Barthez, the development of acute 
pain coincided with the ossification of the fontanelles. 

The general condition of children suffering with chronic hydrocephalus 
varies greatly. 

In some cases they preserve their appetite and digestion, and appear 
well-nourished and strong to a late period in the attack; but more fre- 
quently they present marked evidences of impairment of nutrition. 

The appetite m-xj indeed remain, but the child loses both flesh and 
strength; the bowels are irregular; usually constipated, but alterna- 
ting with temporary attacks of diarrhoea. 

In the majority of cases, perhaps, these symptoms are not sufficiently 
pronounced to establish the character of the attack, until the increas- 
ing size of the head becomes manifest, and the child acquires the dis- 
tinctive physiognomy of hydrocephalus. Even after marked enlarge- 
ment of the head has occurred, however, the advance of the case is far 
from being uniform. In almost every instance there are pauses of the 
most variable frequency and duration, during which the child seems 
free from pain, improves in general condition, and the development of 
the head is temporarily arrested. 

Death is frequently directly induced by some intercurrent affection, 
wholly unconnected with the disease of the brain ; while, in other 
cases, it immediately follows a violent attack of convulsions, or is pre- 
ceded by symptoms of an acute exacerbation of the cerebral disorder. 
In some cases, also, the patients sink into a condition of atrophy, and 
die worn out by the protracted suffering and malnutrition. 

Diagnosis. — During the early stage of the disorder, if the nervous 
symptoms are slight, consisting merely in occasional attacks of heat of 
the head, attended with pulsation or tension of the anterior fontanelle, 
and restlessness and crying, the diagnosis must remain uncertain. 
After the enlargement of the head has progressed to any considerable 
degree, the expression of the little patient, taken in conjunction with 
the other symptoms, is usually perfectly characteristic and conclusive. 

The morbid condition with which it is most likely to be confounded, 
is rickets of the skull. In fact, in some cases, the enlargement of the 
head, which results from these two affections, is quite identical. Usually, 
however, this is not the case ; and the hypertrophy of the rachitic 
bones takes place irregularly, so that the skull acquires a square in- 
stead of a rounded form; the orbital plates of the frontal bones are 
not displaced; so that, although the forehead may be large and over- 



534 CHRONIC HYDROCEPHALUS. 

hanging, the axes of the eyes are not disturbed; the fontanelles are 
not widely open, prominent, or distended; and, finally, of course, fluc- 
tuation on palpation is never present. In addition to this, the evidences 
of rickets in other portions of the body, and the" peculiar symptoms of 
that affection, as detailed in the article devoted to its consideration, 
nearl}^ always enable the diagnosis to be readily made. 

We have alread}' mentioned the changes which ophthalmoscopic ex- 
amination shows in the retina in this disease, and as a similar examina- 
tion reveals no lesion whatever in cases of rachitic enlargement of the 
head, it is evident that the use of the ophthalmoscope may be of mate- 
rial aid in establishing the diagnosis between these affections, which is, 
despite all the points of distinction above referred to, obscure and diffi- 
cult in some few cases. 

In doubtful cases assistance may possibly also be derived from cere- 
bral auscultation; the presence of a bruit over the anterior fontanelle 
being thought by some authors to be a valuable indication of the 
rachitic nature of the enlargement of the skull. The significance of 
this cephalic bruit is, however, so much disputed, that it is at present 
impossible to assign any definite value to it. 

The only other pathological condition with which chronic hydro- 
cephalus is apt to be confounded, is hypertrophy of the brain, an ex- 
tremely rare affection, due to an increase of the interstitial connective 
tissue of the brain, the so-called neuroglia. 

In hypertrophy of the brain, however, the symptoms do not usually 
appear so early as in chronic hydrocephalus, nor is the cerebral dis- 
turbance so marked as in the latter affection. The enlargement of the 
bead, also, which is the most characteristic feature of both conditions, 
is not so great in hypertrophy^ of the brain, and, instead of being uni- 
form and assuming a rounded form as in hydrocephalus, occurs especi- 
ally at the occiput. There is, further, no depression of the orbital 
plates of the frontal bones in hypertrophy of the brain, so that the 
axes of the eyes are not disturbed, and the globes are not displaced in 
the way we have already described as so characteristic of hydro- 
cephalus. 

Finall}", the sutures are not so widely open, nor the fontanelles tense 
and prominent as in hydrocephalus; and, of course, the fluctuation 
which can be detected on palpation in some cases of this latter disease 
is never present. 

Prognosis. — Chronic hydrocephalus still ranks among the most fatal 
diseases ; so much so that Eilliet and Barthez — who, however, attribute 
its production usually to the presence of a tumor in the brain — ex- 
press their belief that it is invariably fatal. Indeed, it must be borne 
in mind that in many cases treatment must necessarily fail from the 
coexistence of some extensive congenital malformation of the brain. 
We should suspect the presence of this complication when there is 
serious disturbance of the nervous system^ such as paralysis, or fre- 
quent and apparently causeless convulsions. Unfortunately, however, 
these hopeless cases cannot always be distinguished. 



TREATMENT. 535 

The prognosis in cases of external hydrocephalus, especially when of 
acute origin, is less unfavorable than when the effusion takes place into 
the ventricles. 

Whatever be the seat of the effusion, however, and the size of the 
head, the case must not be regarded as hopeless and beyond reach 
of remedial measures, so long as the functions of the brain are well 
performed, since there are well-authenticated cases of complete recov- 
ery from chronic hydrocephalus, even when congenital. 

Treatment. — It must be sufficiently evident, from the previous con- 
sideration of this affection, that there are numerous cases in which all 
treatment must prove unavailing, from the serious organic disease of 
the brain which accompanies it. Under any circumstances, however, 
the nature of the treatment and its efficiency will be much influenced 
by the early stage at which it is instituted. 

In regard to the utility of various special remedies, also, there is the 
greatest diversity of opinion ; and, indeed, there is no plan of treatment 
which possesses so much evidence in its favor as that originally pro- 
posed by Professor Golis, of Yienna. 

If the disease be in its incipience, and the constitution and hereditary 
tendencies of the child free from taint, this distinguished physician rec- 
ommends that the head should be shaved, and one or two drachms of 
dilute mild mercurial ointment rubbed daily into its scalp. While this 
treatment is being carried out, the head should be constantly protected 
by a flannel cap. At the same time^ calomel should be given in doses 
of one-sixth to one-fourth gr. twice daily, unless it irritate the bowels, 
when the inunction alone should be continued. 

If after pursuing this treatment, conjoined with the most careful at- 
tention to diet and all hygienic precautions, for five or six weeks, there 
is marked improvement in the condition of the child, the mercurials 
may be gradually discontinued. 

The iodide of potassium has been highly recommended as a substi- 
tute for the mercurials above mentioned, and several cases of apparent 
recovery under its use are on record. It should be given in large 
doses, and for a considerable length of time. Trousseau, who recom- 
mends its use, joins to its internal administration the external applica- 
tion to the head of lotions containing iodine. 

Should the disease remain uninfluenced at the end of this time, it is 
proper to add to the treatment diuretics and counter-irritants, in the 
form of issues in the back of the neck, which may be kept open for 
several weeks. Dr. West recommends the frequent application of 
blisters as a substitute for the use of issues. 

During the employment of this or any other mode of treatment, it 
will be occasionally necessary to have recourse to antiphlogistic reme- 
dies, to subdue the exacerbations of heat and restlessness which occur 
more or less frequently, and threaten the development of an acute in- 
flammatory condition. Nor should we fail to pay attention to the 
proper performance of all the functions; to the maintenance of the 
appetite and digestion by the use of tonics; and in case of the exist- 



536 CHRONIC HYDKOCEPHALUS. 

ence of a Rcrofulous diathesis, to the administration of cod-liver oil, 
iodide of iron, &c. 

When, despite the most careful emploj^ment of well-directed measures, 
the disease is clearly advancing, it is worse than useless to persist in 
any plan of treatment which annoys or absolutely pains the doomed 
child; our only endeavor should then be to subdue any intercurrent 
disorder wliich might hasten the fatal result. 

More than twenty-five years ago, the use of compression of the head, 
to prevent its yielding to the accumulating fluid, was urged by Bar- 
nard, and experience has shown it to be a valuable adjunct to other 
treatment, though it is inapplicable while any acute symptoms are 
present, and according to West is best adapted to cases of external hy- 
drocephalus succeeding to hemorrhage into the arachnoid space. 

M. Trousseau recommends the following mode of applying this pres- 
sure : Strips of adhesive plaster, about one-third inch wide, are passed 
from each mastoid process to the outer part of the orbit of the opposite 
side; from the nape of the neck along the longitudinal sinus to the 
root of the nose; across the whole head, intersecting at the vertex; 
and finally are kept securely in position by a strip passed thrice around 
the head, the ends of the previous strips being turned up over the first 
coil of this strip, and secured by the succeeding turns. 

It becomes necessary to loosen these strips instantly, if any symp- 
toms of compression of the brain develop themselves, since the increas- 
ing pressure of the accumulating fluid may produce irreparable injury 
to the base of the brain, or even, as happened to M. Trousseau, detach 
the ethmoidal bone from its connections. 

The unfavorable results of all strictly medicinal treatment, impelled 
physicians, at an early date, to resort to active surgical interference in 
chronic hydrocephalus, by puncturing the cranium and evacuating the 
fluid. 

The operation should be performed with a delicate trocar and cau- 
ula, the puncture being made in the coronal suture, about an inch or 
an inch and a half from the longitudinal sinus, — and in a majority of 
cases, no evil consequences appear to follow the operation itself. Much 
difference of opinion still exists, however, as to its curative influence. 
From a rigid analysis of 56 reported cases in which this operation had 
been performed, Dr. West came to the conclusion that in only 4 had a 
permanent cure been efl'ected. Other successful cases have been since 
reported, so that the operation must be recognized as at least a justifi- 
able one in certain cases. 

The circumstances favorable to its performance are, when the hydro- 
cephalus is external; or when internal, is due to previous inflammation 
of the lining membrane of the ventricles; when there is no reason to 
believe that the disease is congenital, and attended with arrested de- 
velopment of the brain; when, though the head may be very large and 
increasing in size, the cerebral functions are not seriously impaired; 
and, finally, when the nutrition of the child is still good. 

Until; however, the treatment previously recommended has been 



ECLAMPSIA. 537 

faithfully tried, and unless the disease be evidently advancing, a resort 
to this operation would be incurring grave risks with but slight pros- 
pect of success. 

Brainard, of Chicago, has recently recommended the injection of 
solutions of iodine into the cranial cavity, after puncture and evacua- 
tion of the fluid. He has employed this in at least two cases, without 
the development of any severe symptoms as a direct consequence of 
the treatment. 

One of the cases died at the end of eight months; the other, at the 
date of the report, only thirty-five days after the operation, had shown 
no unfavorable symptoms. 

He advises the use of an aqueous solution of iodine, in the proportion 
of one-third gr. with onegr. of iodide of potassium, to f^j distilled water; 
of this from fjj to f^j, may be injected; the strength of the solution 
and the amount injected being increased at subsequent punctures. 

In one of his cases, twenty-one injections were practised in the course 
of seven months. 

Injections of this strength are usuallj^ followed by no symptoms of 
inflammation whatever; and this exemption has led to the employment 
of much stronger solutions. 

Thus Dr. Tournesko, of Bucharest (quoted by Bouchut), injected 
f3iij tr. iodine in f5v distilled water, immediately after having drawn 
ofl" by puncture f^xxiv of serum. The operation was followed by 
slight febrile excitement; but, at the expiration of fifteen daj^s, the 
child seemed in excellent health, the circumference of the head having 
diminished from 56i to 43 centimetres. 



AETICLE yi. 

GENERAL CONVULSIONS, OR ECLAMPSIA. 

G-ENERAL Eemarks. — The word convulsions is a generic term applied 
to diff'erent forms of spasmodic disease, very dissimilar from each other 
in many of their characters. 

Writers make diff'erent classifications of convulsions according to 
their peculiar notions in regard to the nature and causes of these dis- 
orders. The best division is, it seems to us, that adopted by most 
French writers, who arrange them by their supposed causes, making 
three classes, idiopathic^ protopathic or essential, sympathetic or deutero- 
pathic, and symptomatic convulsions. The first two classes are unac- 
companied by appreciable lesions of the nervous centres, while the 
third is called symptomatic, because it includes cases of convulsions 
which are the sign or symptom of an appreciable lesion of the cerebro- 
spinal axis, as for instance, those which occur in the course of menin- 
gitis, tubercular disease, hydrocephalus, apoplexy, &c. In idiopathic 



538 ECLAMPSIA. 

or essential convulsions, the cause of the attack acts directly upon the 
nervous centres, while in those to which the term sympathetic is ap- 
plied, the cause lies in the influence or effect upon the brain or spinal 
marrow of disease of some other organ; to the latter class belong the 
convulsions which occur in the course of pneumonia, bronchitis, the 
eruptive fevers, &c. 

We shall not pretend to give an accurate account of s^miptomatic 
convulsions in this article, as they have already been treated of under 
the head of the different organic diseases of the brain in the course of 
which they occur. We shall refer to them in the present article only 
so far as may be necessary to elucidate the pathology, diagnosis, prog- 
nosis, and treatment^ of idiopathic and sympathetic convulsions. 

There is a form of eclampsia occurring in children, w^hich we shall 
describe separately, as it differs in many of its characters from ordinary 
convulsions. This is the disease known by the names of spasm of the 
glottis, thymic or Kopp's asthma, laryngismus stridulus^ and eclampsia 
with suffocation. 

Definition; Synonyms; Frequency. — By the term convulsion is 
meant a paroxysm of variable duration, usually attended with uncon- 
sciousness, and followed by stupor, and characterized by a primary in- 
voluntary tonic contraction followed by irregular clonic spasms of the 
affected muscles. 

In general convulsions, to which the above definition especially ap- 
plies, the entire system of voluntary muscles is usually affected; though, 
as will be described hereafter, the attack may be a complete and genuine 
one of eclampsia, and 3'et the convulsive movements be limited in their 
extent to a single group of muscles, or even a single muscle. 

The only synonyms which it is necessary to mention are epilepsia 
puerilis, insiiltus ejrilepticus, and eclampsia. The latter term, eclampsia, 
is, we believe, preferable to any other, and we would gladly introduce 
it instead of convulsions, which is too general a term to express the 
form of disease under consideration. 

The frequency of eclampsia is very great. During the five years 
from 1844 to 1848 inclusive, 1729 children under fifteen years of age 
died in this city of convulsions; whilst, during the same time, 1611 
died of infantile cholera, 1060 of marasmus, 1041 of dropsy of the brain, 
and 772 of pneumonia, showing that eclampsia was the cause of a 
larger number of deaths than any other of the diseases just mentioned. 
It must be recollected, however, that a very large number of these 
cases ought, beyond doubt, to have been returned under other titles, 
as many of them must have been a mere result of organic disease of 
the cerebro-spinal axis, and of other acute local or general diseases. 

Predisposing Causes.— Essential and sympathetic convulsions are 
much the most frequent before the age of seven years, which is the 
case also in regard to symptomatic convulsions, though the latter oftei> 
occur after the age mentioned. Of 91 cases of convulsions that we 
have met with, in which the age was noted, 19 occurred in the first 
year, 26 in the second, 20 in the third and fourth, 23 between the 



CAUSES. 539 

fourth and ninth, and 3 between the ninth and thirteenth j^ears of life. 
Dr. AYest (^op. cit., p. 42) states that according to the Fifth and Eighth 
Reports of the Eegistrar-General, the deaths from diseases of the ner- 
vous system in London, under one year of age, bore a proportion 
of 30.5 per cent, to the deaths from all causes; from the first to the 
third year, the proportion was 18.5 per cent. ; from the third to the fifth 
year it was 17.6 per cent.; from the fifth to the tenth year, it was 15.1 
per cent.; whilst from the tenth to the fifteenth year it was only 10.6 
per cent., and the total above fifteen years was but 10.4 per cent. Again, 
to show the vqyj great influence of age upon the predisposition to con- 
vulsions. Dr. West states that, within the first year, the deaths from 
convulsions constituted 73.3 per cent, of the total mortality from dis- 
eases of the nervous system; between the first and third j^ears, the pro- 
portional mortality from convulsions to the total mortality from afi'ec- 
tions of the nervous system, was 24.9 per cent.; between the third and 
fifth years, it was 17.8 per cent.; between the fifth and tenth years, it 
was 9.9 per cent.; while between the tenth and fifteenth years it had 
fallen to 2.4 per cent.; and above fifteen years it was but 0.8 per cent. 

Dr. West ascribes the great frequency of convulsions in early life to 
the predominance of the spinal over the cerebral system, and to the im- 
perfect development of' the brain. 

It is generally stated that convulsions are more common in girls than 
boys. MM. Eilliet and Barthez found this to be the case in their private 
practice, whilst in the hospital, sympathetic and symptomatic convul- 
sions were most frequent in boys. According to our experience, they 
have been almost equally frequent in the two sexes, since of 92 cases 
that we have seen in which the sex was recorded, 47 occurred in boys 
and 45 in girls. 

It has been generally supposed that a delicate and nervous constitu- 
tion is a powerful predisposing cause to convulsive attacks. This has 
been denied, however, by several recent writers, whose observation is 
very careful and accurate. We are disposed to believe that it is not so 
much a feeble or delicate constitution that predisposes to convulsions, 
as it is one characterized by a highly susceptible, irritable, and nervous 
temperament, which often exists, in our opinion, in connection with a 
healthy and vigorous physical organization. Of 96 children in whom 
we have seen convulsive attacks, these occurred more than once in 13. 
Of the 13, nine presented every appearance of strong and vigorous 
health, with the exception that when laboring under any kind of sick- 
ness, as dentition, indigestion, the fever accompanying simple angina, 
in two the invasion of measles, and in one that of erysipelas, they im- 
mediately became extremely restless and irritable, or heavy and drowsy, 
and at a very early period, and sometimes with very little warning, 
were seized with convulsions. In one, a well-developed infant in its 
first year, the convulsions occurred every month or six weeks, without 
any appreciable cause. Three of the 13 were delicate : one was puny and 
feeble until after the completion of the first dentition, when it grew 
strong and hearty; one had had an apoplectic attack when an infant 



540 ECLAMPSIA. 

which had caused partial loss of power of one side; and the third was 
very weak at birth, then grew stronger, and died in its second year of hy- 
drocephalus following scarlet fever. The number of convulsions varied 
in the different subjects. In 1 there were five different attacks, in an- 
other four, in 4 there were three, and in 5, two. In two the attacks 
were very numerous, recurring frequently, and from very slight causes, 
or without any appreciable cause. They all recovered but two, and are 
still living. Of the 11 now living at various ages, all but one are free 
from anything like epilepsy, and that one, though liable during three 
years to attacks of an epileptiform character, became gradually less 
and less subject to the seizures, and has now been for several years per- 
fectly well in all respects. 

We have another patient, a bo}^, whose case is not included amongst 
the above, now five years old, who has had ten different attacks of con- 
vulsions. These attacks were all produced by some disturbance of his 
health. Several of them have occurred at the outset of a febrile re- 
action caused by a simple catarrh of the upper air-passages^ — the con- 
vulsions ushering in the catarrh just as they sometimes do an attack 
of measles or scarlet fever. On other occasions, the seizure has evi- 
dentl}'' been the result of a febrile movement caused by indigestion or 
gastric irritation. After having had nine different attacks, he remained 
free from them for a whole year, and then had the tenth at the very 
beginning of a catarrh of the larynx, fauces, and nasal passages. This 
child has never as yet exhibited any symptom whatever of disease, 
either acute or chronic, of the cerebro-spinal axis, and as the convul- 
sions have always been connected with a febrile movement, there is 
every reason to hope that they are not epileptic. Another patient, 
likewise not included amongst the above, a girl now five years old, has 
also had frequent attacks, but as they are of short duration, always 
coincident with the fever of catarrh, or digestive disorder, and on one 
occasion that of measles, and as between the seizures her health is ex- 
cellent, there is but little reason to fear epilepsy. 

It is generally believed that the predisposition to convulsions is 
sometimes hereditary. We have remarked in regard to this point, 
that several children in the same family sometimes suffer from the 
disease, and that the nervous temperament to which we alluded above, 
appeared in some instances to have been inherited by the child from its 
parents. 

In one family that we attend, out of six children, all but one have 
had attacks of convulsions : one of these children had but one attack, 
and that was at the age of ten years, and was caused by a fit of indi- 
gestion occurring during convalescence from pneumonia. The other 
four children had each several attacks, occasioned always by the feb- 
rile movement resulting from some of the numerous disorders of infancy. 
In none of these has there been any reason to suppose that the attacks 
were settling into epilepsy. 

Some very interesting evidence confirmatory of this view has re- 
cently been furnished by Dr. Eobert P. Harris, of this city, in an article 



SYMPTOMS. 541 

read before the Philadelphia Obstetrical Society (see Amej\ Jour, of Ob- 
sfet., vol. ii, No. 2, August, 1869). 

His record embraces 38 cases of eclampsia, 37 of which occurred in 
13 families, in which, collectively, there were 55 children who lived 
long enough after birth to prove their liabilitj^ or exemption ; 4 having 
died too early to determine Avhether they were subject to convulsions 
or not. 

All of the individuals included in the statistics were descendants of 
the first, second, or third generations, of two pairs of ancestors; of 
the present rising generation (the second) there are 31 members, only 
one of whom has as yet married; twenty of the 31 have had convul- 
sions. 

The exciting causes of convulsions are exceedingly numerous and dis- 
similar. Amongst the causes of essential convulsions are cited vivid 
moral emotions, violent pain, high temperature, exposure with the 
head uncovered to the sun, and sudden exposure to cold. In many 
cases, however, the exciting cause cannot be detected. The exciting 
causes of sympathetic convulsions may be almost any of the diseases 
incident to childhood. Amongst them we will cite as the most fre- 
quent, hooping-cough, pneumonia, catarrh, scarlatina, measles, violent 
fever from any cause, dentition, and indigestion. 

Of 96 cases of convulsions, of which we have preserved notes, we 
have regarded only 4 as essential, while 70 were sympathetic, and 22 
symptomatic. Of the 4 essential cases, we could not detect the excit- 
ing cause in any. Of the 70 sj^mpathetic cases, it was scarlet fever in 
12; pertussis in 9; indigestion in 13; pneumonia in 3; the fever of 
simple angina in 6; cholera infantum and bronchitis, each 3; dysen- 
tery, 4; measles and dentition, each 6; enteritis, the fever and irrita- 
tion caused by a burn upon the back, and the onset of erysipelas, each 
1 ; an overdose of castor oil (5vj) given to a young child with a slight 
cholera, 1; and lastly, fecal accumulations in the large intestine, 1. 

Symptoms. — Prodromic /Symptoms. — It has been asserted by some 
writers that most attacks of convulsions in children are preceded by 
prodromic symptoms, which indicate to the experienced eye their 
approach. This does not agree exactly with our own experience, at 
least in regard to the essential and sympathetic forms, since of the cases 
of the former variety, well-marked prodromes did not occur in any, and 
of 64 cases of the latter, in which the early symptoms were noted, 
strongly-marked precursory phenomena occurred only in 8. We do 
not mean to say that there were no symptoms in the other 56 cases 
which might have indicated to an experienced eye the probability of 
an approaching attack of convulsions, but merely that there were none 
that were strikingly characteristic, none which pointed out clearly and 
decisively that such a crisis was close at hand. In many of the 56, 
there were symptoms that might be regarded as indicating, with vari- 
ous degrees of probability, the approach of the convulsive seizure; but, 
inasmuch as they were such as constantly exist in children not predis- 
posed by temperament or constitution to eclampsia, without the devel- 



542 ECLAMPSIA. 

opment of the disease, they scarcely deserve to be called precursory 
symptoms. 

The precursory symptoms of idiopathic and sympathetic convulsions 
are, therefore, difficult to describe because of their variable and uncer- 
tain character. They consist in general, however, of whatever indi- 
cates a highly disordered condition of the nervous system. The most 
marked symptoms are unusual drowsiness, excessive irritability, a pe- 
culiar physiognomical expression, general tremors, and the drawing 
of the thumbs into the palms of the hands, or rigid flexion of the toes. 
The drowsiness which precedes an attack of eclampsia, is almost al- 
ways accompanied with some restlessness. The sleep is light and 
easily disturbed; the child moves and turns, or starts and moans; often 
it seems to have frightful dreams, and will scream out or wake sud- 
denly bewildered and terrified, and when roused is generally exceed- 
ingly irritable, crying violently or fretting at the slightest contrariety, 
or without cause. The face, and particularly the eyes, often exhibit a 
peculiar expression, altogether different from their 'usual appearance. 
The expression which has most struck us, and which we have seen on 
several occasions, is a fixed and staring look, lasting but for an instant, 
as though the child were looking intently at some object, while in fact 
it is gazing at vacancy; at the same time the expression is entirely 
without meaning. The child seems, in fact, for a moment, to be in a 
state of ecstasy. In some instances a sardonic smile is seen to pass 
over the countenance just before the attack. The tremors or trem- 
blings alluded to above, occur both in the sleeping and waking state, 
but particularly in the former. Flexion of the thumbs and toes has 
been noticed by different observers, but is, we believe, a sign rather of 
the approach of symptomatic, than of essential or sympathetic convul- 
sions. 

The precursory symptoms of symptomatic convulsions will depend 
on the nature of the disease in the course of which they occur, ^ot 
unfi-equently the convulsions occur at the very outset of the disease of 
the brain or spinal marrow, when of course there will be no prodromic 
symptoms whatever. According to Dr. Marshall Hall (^Diseases of the 
Nervous System, p. 14:9), the first and most frequent sign showing that 
the excito-motory system is becoming complicated in diseases of the 
brain is vomiting, after which come strabismus^ a contracted state of 
the muscles of the thumbs or fingers, or some unequivocal spasmodic or 
convulsive affection of the respiratory muscles, or of the muscles of 
the limbs. 

Symptoms of the Attack. — With or without the precursory symptoms 
just described, the convulsion itself usuallj^ begins suddenly. The child 
often utters a cry; loses consciousness and is seized with powerful tonic 
contra(.*tion of the voluntary muscles; the eyes are for a moment fixed 
and staring, and then drawn obliquely upward under the upper lid, so 
that the white portions of the balls alone are visible for an instant 
between the partially open lids; the trunk is rigid and stiff, the thorax 
immovable, the respiration suspended by rigid spasm of the respiratory 



SYMPTOMS. 543 

muscles; the face, for a moment pale, iisiiall}" becomes livid and conges- 
ted, and the veins of the neck are distended. 

This state of tonic spasm is followed quickly by the stage of clonic 
spasm, in which involuntary and most irregular convulsive movements 
occur. The eyes are rarely fixed in one position, but are constantly 
agitated in various directions, from side to side, or upw^ards and down- 
wards; very often there is the most violent strabismus; the eyelids are 
sometimes open, at others shut ; the pupils may be contracted or dilated. 
The muscles of the face next enter into contraction, and occasion the 
most hideous contortions of the features. The mouth is distorted into 
various shapes, the lips are often covered with a whitish or sanguinolent 
froth, and the jaws tightly clinched together by tonic spasms, or agitated 
by convulsive movements, so as to produce grinding of the teeth. The 
trunk of the body is also sometimes variously contorted by clonic con- 
vulsions. The head is usually strongly retracted upon the trunk, but 
in other instances is drawm to one side, or violently rotated. The 
muscles about the -front of the neck enter into action, and alternately 
elevate and depress the larynx; the tongue, when it can be seen, is ob- 
served to be moved in different directions, and is sometimes caught 
between the teeth and severely bitten. The extremities, particularly 
the superior, are more violently convulsed than any other parts. The 
fingers are drawn into the palms of the hands, the forearms are flexed 
and extended upon the arms by short, rapid, and generally rhythmical 
movements, the hand is quickly pronated and supinated upon the arm, 
or finally the whole upper extremity is twisted and distorted into vari- 
ous positions, which it is impossible to describe. The inferior extremi- 
ties undergo similar movements, but almost always in a less degree than 
the upper. The respiration during the attack is irregular, sometimes 
suspended by rigid spasm of the respiratory muscles, and sometimes 
accelerated. A spasmodic contraction of the larynx, producing noisy 
inspirations, has been noticed by several writers. We shall find when 
we come to consider the nature of this disease, that Dr. Hall was of opin- 
ion that a more or less complete closure of the larynx is the most im- 
portant feature of the convulsive crisis. The face is often livid and 
deeply congested, especially when the respiration is embarrassed; the 
head is hoi, whilst the extremities are cold; the pulse becomes large 
and full, or frequent and small, and sometimes cannot be counted in 
consequence of the contractions of the muscles of the forearm. The 
face is not always however congested. We have sometimes seen it 
perfectly white, while the convulsions were severe, and the child pro- 
foundly insensible. The action of the heart is tumultuous, and some- 
times irregular or intermittent. When the attack is very violent, the 
urine and fseces are occasionally discharged involuntarily, but these are 
rare symptoms. Deglutition is seldom impossible even in the severest 
fit. In severe, and especially in long-continued attacks, intellectual con- 
sciousness, and general and special sensibility, are all abolished. In 
milder cases, though consciousness is destroyed, some of the special 



544 ECLAMPSIA. 

Benses still respond to irritants, whilst in still slighter cases, the intelli- 
gence also is more or less preserved. 

As the termination of the attack approaches, the convulsive move- 
ments become more and more feeble, until they finally cease entirely, 
and the child falls into a state of deep sleep, or of more or less profound 
stupor. 

Convulsions are not always, as we have just described them, general. 
They may be circumscribed or partial, affecting one side of the body 
more than the other, or one side alone, or a single arm, or in some cases, 
indeed^ only a single muscle, as the biceps. Sometimes they implicate 
the eyes only. The inferior extremities are rarely affected alone. Of 
the partial convulsions the most frequent are those in which some parts 
of the face and upper extremities are attacked. In this form of the 
disease, the disorders of the circulation and respiration, the congested 
tint of the face, the froth upon the lips, and the derangements of intel- 
ligence and sensibility, are much less strongly marked than in general 
attacks. 

In still other cases, which have been by various authors grouped 
together under the objectionable title of "inward convulsions," the 
spasm affects chiefly the muscles of respiration ; at times being limited 
to the muscles of the larynx, and constituting the affection we shall 
describe in a special article under the name of laryngismus stridulus; 
at others affecting principally the diaphragm and the thoracic and ab- 
dominal muscles of respiration. 

The duration of an attack of eclampsia concerns both the length of 
the convulsive crisis and the continuance of the disposition to renewals 
of the crisis. Both of these are very uncertain. We have known the 
attack to last in all its violence eight hours and a half in one case, and 
twelve in another, and it is said to have lasted much longer in some 
instances. When the spasmodic movements continue during a long 
period, they are almost always interrupted by remissions. As a general 
rule, the duration is much shorter than the periods above mentioned, — 
from a few minutes to half an hour. When the attacks cease and recur, 
as they often do, several times a day, they leave the patient during the 
intervals in a state of more or less perfect consciousness or somnolence, 
restlessness or delirium, or finally of coma. The period during which 
the disposition to recurrence continues, depends principally upon the 
cause of the convulsions. If this continue in action, they will be apt 
to return until it is removed. 

Idiopathic and sympathetic convulsions generally consist of a single 
attack, though there are sometimes several, which occur at intervals of 
some hours, or of one or two days. Sympathetic convulsions usually 
occur cither at the beginning or termination of the disease which they 
complicate, and much less frequently during its middle period. Of 46 
cases of this form observed by ourselves, complicating measles, scarlet 
fever, erysipelas, pneumonia, bronchitis, cholera infantum, simple an- 
gina, and dysentery, in which the period was carefully ascertained, they 
occurred at the invasion alone in 25, at the termination alone in 15, at 



NATURE OF THE DISEASE. 545 

the middle period alone in 3, and at the invasion and termination both 
in 3. It is curious to remark, that of the 25 cases that occurred only 
at the invasion of the disease, all but 7 recovered ; that the 3 occurring 
in the middle period alone, also recovered ; that of the 3 occurring 
both at the invasion and termination. 2 died; and that all of those 
which occurred at the termination alone, proved fatal. 

MM. Eilliet and Barthez state that half the cases of symptomatic 
convulsions observed by them, occurred at the commencement of the 
encephalic disease. This form seldom consists of a single crisis; the 
attacks, on the contrary, are repeated from time to time. The authors 
just quoted state that whenever the convulsive attacks have recurred 
repeatedly within a period of a few days, they have proved symptom- 
atic of disease of the brain. 

Kature of the Disease. — One of the most important contributions 
which has been made towards a plausible and satisfactory explanation 
of the pathology of convulsions in children, was afforded us in the 
writings of Dr. Marshall Hall; and, although more advanced knowl- 
edge of the physiology of the nervous system has shown that the part 
of the cerebro-spinal axis involved in the production of convulsions is 
not limited, as he supposed, to the true spinal system, his theory of ex- 
cito-motor action furnishes the most ready explanation of very many 
cases of eclampsia. Dr. Hall says {Diseases and Derangements of the Ner- 
vous System, p. 145) : " That the whole class of convulsive diseases con- 
sists of affections of the true spinal system, there is no longer any 
doubt. But these diseases do not all originate in this system." All 
convulsive disorders are, according to this doctrine, affections of the 
true spinal or excito-motory system. The causes of these disorders 
may be of incident origin, acting upon excitor nerves; of centric 
origin, seated in the brain or spinal marrow ; or of reflex origin, acting 
upon reflex or motor nerves. They are called, therefore, according to 
their causes, central or centric, when they depend on disease of the 
nervous centres ; centripetal when they are excited through excitor 
nerves ; and centrifugal when they depend on disease of the motor 
nerves. 

Dr. Hall, as is well-known, ascribed great importance to the condi- 
tion of the glottis in convulsions. He says (p. 323), in speaking of 
epilepsy, " The second symptom is a forcible closure of the larynx and 
expiratory efforts, which suffuse the countenance and probably congest 
the brain with venous blood." At page 327, he says: " A spasmodic 
affection of the larynx has obviously much to do in this disease 
(epilepsy), as well as in the crowing inspiration or croup-like convul- 
sion of infants; so much, indeed, that I doubt whether convulsion would 
occur without closure of this organ." In describing the croup-like con- 
vulsion or laryngismus stridulus (p. 180), he says : '' I must repeat 
the observation that the respiration is actually arrested by the closure 
of the larynx; and there are forcible expiratory efforts only or princi- 
pally in the actual convulsion." In a later publication, Dr. Hall says : 
"Without closure of the larynx, extreme laryngismus, and the conse- 

35 



646 ECLAMPSIA. 

quent congestion of the nervous centres, there conld I believe be no 
convulsion ! This closure of the larynx must be complete in the affec- 
tion under consideration (laryngismus stridulus), as in all others, before 
convulsions can take place." {Braith. Bet, from Lancet, June 12th, 1847, 
p. 609.) 

It is, however, evident tliat the obstruction to respiration exists not 
only in the larynx, but in the thorax, the muscles of which are rigidly 
contracted.- Nor can we at present admit that this spasm of the mus- 
cles of respiration is more than coincident with the other phenomena 
of the convulsive attack : and, indeed, there are reasons for believing 
that the accumulation of venous blood in the nervous centres which 
follows the obstruction of respiration, so far from causing the convul- 
sion, has a tendency to arrest it, and to induce a state of coma. 

It is, however, easy to comprehend the mode of production of sym- 
pathetic convulsions by reference to these doctrines. They evidently 
depend upon morbid impressions conveyed to the cerebro-spinal axis 
through the excitor nerves having their origin in the diseased organs, 
probably conjoined with a state of undue reflex excitability of certain 
parts of the nervous centres. Thus it is easy to understand why in- 
flammation of the parenchyma of the lung in pneumonia, of the bron- 
chial mucous membrane in bronchitis, of the mucous membrane of the 
bowel in eutero-colitis or dysentery, or the pharynx in angina; why 
the pressure of a tooth upon an inflamed gum during dentition, the 
presence of a foreign body, as newspaper (in one of our own cases), or 
crude food, in the stomach, or fecal, or lienterie accumulations in the 
intestine, should produce a degree of irritation in excitor nerves, suffi- 
cient, when transmitted to the sensori-motor ganglia, to occasion the 
convulsions we have been considering. 

It is more difficult to explain the mode in which continued fevers, 
measles, scarlatina, &c., give rise to convulsions. To us, however, their 
occurrence is explicable by the morbid effect produced upon the ner- 
vous centres by the blood, which is known to be more or less changed 
in these affections from its healthful condition, and also by the mere 
fact of the existence of fever; for we have met with a number of chil- 
dren in our own practice, who are almost certain to have a convulsive 
seizure, whenever the circulation becomes greatly excited in force and 
frequency by the existence of fever, no matter what be its cause. 

The explanation of the production of idiopathic or essential convul- 
sions is not always so easy, because we are sometimes unable to detect 
any cause, either centric, centripetal, or centrifugal, to account for 
the excitation of the nervous system. It seems probable, however, 
that they must depend, like those of the sympathetic form, upon some 
unhcalthful, and therefore irritating condition, acting upon the excito- 
motory system of nerves. The cause may be so slight as to escape the 
notice of the physician, and yet suflScient to produce a convulsive crisis 
in a child predisposed to eclampsia. It may be an unnoticed dentition, 
some undigested food in contact with the stomach or intestines, or ac- 



DIAGNOSIS. 547 

cumulations of unhealthy fecal substances, or of vitiated secretions, in 
the intestines. AYhen convulsions have followed a vivid mental emo- 
tion, as passion or vexation, they are evidently a result of the influence 
of that condition upon the nervous centres. Acute pain, which is said 
to have occasioned essential eclampsia, as well as exposure to violent 
heat or severe cold, must produce their effects through their action 
upon incident excitor nerves. There is also in all probability, in most 
children who suffer with convulsion, a state of preternatural mobility 
and increased reflex excitability of certain parts of the cerebro-spinal 
axis, which predisposes to disorderly nervous action, even upon trifling 
causes. There can be no doubt that this irritability of the nervous 
sj'stera is frequently inherited, though it may be acquired in the course 
of chronic debilitating diseases. Although we have described these 
convulsions under the title of essential and sympathetic, we do not mean 
to assert that the}' are absolutely independent of any material changes 
in the nervous centres, but merely that, up to the present time, no ap- 
preciable lesions have been detected as their causes. It is indeed true, 
that, in a certain number of instances, after death from eclampsia, there 
are found engorgement of the vessels of the membranes and of the sub- 
stance of the brain, serous effusion into the cavity of the arachnoid or 
the lateral ventricles, or even actual cerebral hemorrhage. But these 
lesions cannot be considered as the causes of the convulsive attack, but 
on the other hand must be regarded as the direct result of the convul- 
sion, and due to the intense vascular engorgement caused by the spasm 
of the respiratory muscles and the consequent arrest of the venous cir- 
culation. And indeed it is the danger of the occurrence of such lesions 
which imparts much of the gravity to the prognosis in all severe attacks 
of eclampsia in young children. 

All symptomatic convulsions belong, of course, to the class of centric 
diseases. These need no further remarks. 

Diagnosis. — There are two important points to be considered in 
treating of the diagnosis of eclampsia: the diseases with which it may 
be confounded, and the causes which may have produced the convul- 
sions, or, in other words, their distinction into essential, sympathetic, 
and symptomatic. 

The only disease with which eclampsia is likely to be confounded, is 
epilepsy; the mistake could only be made when the former is violent, 
and when it is accompanied and followed by unconsciousness. In epi- 
lepsy, however, the invasion is more sudden, the convulsions are ac- 
companied with greater rigidity, there is always frothing at the mouth, 
tlie duration of the crisis is shorter, and it is generally followed by more 
marked stupor. If the convulsive attack have occurred under the in- 
fluence of an appreciable cause, if the parents are not epileptic, and if 
the child is very impressionable, it is probably eclampsia. Again, the 
younger the patient, the more likely is the case to be one of eclampsia ; 
whilst if the child is approaching towards puberty, if the attacks are 
frequently repeated, and yet not dependent on fever, and if they are 



548 ECLAMPSIA. 

foUoTved by complete restoration to health in the interval, the disease 
is much more likely to be epileps}^ 

The diagnosis of the form of the attack, whether idiopathic, sympa- 
thetic, or s^^mptomatic, is exceedingly important, as upon this must de- 
pend in great measure the prognosis and treatment. It is often very 
difficult, and sometimes impossible, to determine at the moment to 
which class the convulsions belong. The most difficult points in the 
diagnosis are the following : first, when a child previously in good 
health, is suddenly seized with the disease, to determine whether it is 
essential; whether it is sj^mpathetic and occasioned by disease which, 
up to this instant, has been latent, or by the invasion of some one of 
the acute local diseases, or of one of the continued fevers; or lastly, 
whether it is symptomatic, marking the invasion of a disease of the 
cerebro-spinal axis: second, when the convulsion occurs in the course 
of a disease not primarily implicating the nervous centres, to determine 
whether it is merely sympathetic of that disease, or whether it is symp- 
tomatic of an intercurrent affection of the brain or spinal marrow. 

It is impossible, for want of space, to treat of all these points in de- 
tail. The enumeration of them, however, will be useful in calling the 
attention of the reader to their importance. 

An essential convulsion is only to be distinguished by careful study 
of the antecedent history and present condition of the patient. If, after 
a thorough examination of all the organs, no diseased point can be de- 
tected, and if the child recover perfectl}^ from the convulsion, we must 
conclude that the case has been an idiopathic one, in which the cause 
is beyond our reach. lYe are disposed to believe, however, as has 
already been stated, that in most such cases there has been a source of 
irritation in some of the organs of the body, which has acted as the 
excitant to the excito-motory system, and which, if we could but detect 
it, would warrant us in classing the case amongst sympathetic convul- 
sions; and on this account a searching physical examination should be 
made in every case, as a matter of course. 

The sympathetic and symptomatic forms of eclampsia are to be diag- 
nosticated by the same careful attention to the antecedent history and 
present condition of the child. If the latter is teething at the time of 
the fit, and there is no other cause to exj)lain the attack, and should 
there be nothing in the consecutive symptoms to render such an ex- 
planation inadmissible, we may refer it to that condition. We may 
remark merely, that, as a general rule, eclampsia depending entirely 
upon the irritation of dentition, is seldom either violent or long-contin- 
ued, and that the return to consciousness and health is speedy. The 
probable dependence of the attack upon indigestion is to be ascertained 
by the absence of other causes, and by our learning upon inquiry that 
the child had eaten of some indigestible substance within a few hours 
or a day or two before the attack. Its dependence on intestinal accu- 
mulations is to be arrived at by the same negative or exclusive method, 
and by learning that the patient is usually, or has been of late, of a 
constipated habit. 



PROGNOSIS. 549 

When the attack occurs in the course of some other disease, as pneu- 
monia, catarrh, enteritis, pertussis, scarlatina, or measles, it is almost 
certainlj' sympathetic. It maj^ 230ssibly, however, be indicative of an 
intercurrent attack of cerebral disease. This can be determined only 
by attention to the consecutive phenomena. If the attack be short, 
and soon followed by complete restoration to consciousness, it is in all 
probability sympathetic. If, on the contrary, the convulsive crisis be 
long and severe, if the recover}' from it be slow and imperfect, if it be 
followed by violent agitation, somnolence, or coma, or by some persist- 
ent lesion of motility, there is every reason to fear an attack of disease 
of the brain. 

Sympathetic convulsions, occurring at the invasion of different local 
or general diseases, are to be distinguished only by observation of the 
symptoms that follow the crisis, which will be those belonging to the 
particular malady whose approach has caused the attack of eclampsia. 

Symptomatic eclampsia is characterized by various signs of en- 
cephalic disorder, which soon follow the convulsive attack. The most 
important of these are severe and continued headache; diminution or 
exaltation of general or special sensibility; dilatation or contraction 
of the pupils; irregular movements of the eyes; flexion or stiffness of 
some of the limbs, or of the fingers or thumbs; disordered intelligence; 
or the symptoms which have already been described in the articles 
upon the diseases of the brain. 

Prognosis. — The prognosis of essential convulsions must depend on 
the nature of the cause and the violence of the attack. When the 
cause has been slight, or one which soon ceases to act, or can be read- 
ily removed, the prognosis is much more favorable than under opposite 
conditions. If the convulsive crisis is short and of moderate severity, 
if the pulse and respiration are but slightly disturbed, if there be but 
little congestion of the face, and no stertor, there is every reason to 
hope a successful issue in the case. Of the three cases of this class 
that we have seen, two recovered and one died. 

Sympathetic is more dangerous than essential eclampsia, but much 
less so than symptomatic. The prognosis will depend chiefly on the 
nature of the disease which it complicates, and on the stage of that 
disease at which it occurs. Thus, in scarlatina, convulsions, especially 
when the}^ occur in the first few days of the disease, are almost always 
fatal, in measles much less so, and in other diseases in various propor- 
tions. They are very apt to terminate unfavorably when they occur 
after the malady which they complicate has been in progress for several 
days. This is a remark made by various authors, and we have already 
stated that of 46 cases of this form in which we carefully ascertained 
the period of their occurrence, 25 appeared at the invasion, of which 
all but 7 ended favorably; 8 at the middle period, which all recovered; 
3 both at the invasion and at a later period, 2 of which were fatal; and 
15 after the cases had been progressing for a considerable time, all of 
which proved fatal. In addition to these important elements for mak- 
ing the prognosis, we must consider, also, the duration and degree of 



550 ECLAMPSIA. 

violence of the paroxj^sm, the state of the patient after the fit as to its 
cerebro-spinal functions, and lastly the age and constitution of the 
child. 

The prognosis of symptomatic convulsions must depend very nniich 
upon that of the disease of which they are the symptom. It may be 
stated, as a general rule, that, like those of the sympathetic class, they 
are less dangerous when they occur at the beginning than at a later 
period of the disease. They are always, however, very dangerous. Of 
22 cases that we have seen, 19 were fatal. 

It frequently happens, however, that although life is not destroyed 
by the convulsions, certain grave sequelse remain, among which the 
most frequent are paralysis, disorders of the mind, and defects of 
speech or vision. These sj^mptoms are, it is true, far most frequent in 
cases of symptomatic convulsions, where they depend upon the same 
lesion of the brain which occasioned the fit. They may, however, suc- 
ceed convulsions which we are still obliged to call essential, although 
there very possibly is some minute alteration or defect in a part of the 
nervous centres, which our means of observation do not suffice to de- 
tect. In such cases these sequelae probably depend upon some lesion 
of the brain, such as cerebral hemorrhage, which has occurred as a re- 
sult of the convulsion. 

Hemiplegia, which is the form of paralysis which most frequently 
follows eclampsia, is most apt to occur when the fit has been limited to 
one side of the body; it is often temporary, and passes away in a few 
dsijs, though it may remain persistently. Dr. J. Hughlings Jackson 
suggests that, in the absence of evident disease in such cases of unilat- 
eral convulsion and palsy in children, the symptoms may depend upon 
the plugging of very small vessels in the brain. 

Treatment. — We shall confine our remarks upon the treatment of 
eclampsia to the essential and sympathetic forms of the disease, having 
already treated of that of the symptomatic form in the articles upon 
the cerebral diseases which give rise to it. 

We think that the treatment of eclampsia in children may be simpli- 
fied if we pay attention to two distinct conditions of disorder, which 
appear to exist in every case. These are the condition of morbid irri- 
tation or derangement of the excito-motory system of nerves, and the 
cause which occasions that derangement. The condition of irritation 
or disease of the cerebro-spinal axis exists in all cases, and is always 
the same, differing only in degree and extent; whilst the morbid cause 
of that irritation differs in each case^ being in one dentition, in another 
pain, in another constipation, in others pneumonia or indigestion, pleu- 
risy, catarrh, or angina, scarlet fever, measles, fright, or other violent 
emotions. If this view of the subject be correct, it is clear that in 
treating a case of convulsions we have to attend to the two morbid 
conditions referred to, and we shall be careful, therefore, in the course 
of our remarks, to treat of the remedies most proper for the removal 
of the cause, whatever it may be^ which acts as the irritant to the 



TREATMENT. 551 

nervous centres ; and of those calculated to subdue or allay the deranged 
condition of those centres and the effects of that derangement. 

There are some general rules to be followed in the treatment of con- 
vulsions which apply to all cases, and of these we shall first speak. They 
are, to place the child in a large well-ventilated room, if such can be pro- 
cured ; if it have been seized in a little close room, where the atmosphere 
is dense and impure, removal to another room, or exposure to fresh air 
before an open window, has sometimes sufficed to terminate the crisis. 
At the same time the clothes of the child should be loosened, in order 
to prevent all constriction, and, if necessary, taken off, to allow of a care- 
ful examination of the whole body. We believe it is a good rule always 
to place the child, no matter what be the cause of the convulsion, if it 
be a severe one, in a warm-hath (96° or 97° F.). This has frequently 
proved an efficient remedy, according to our experience. It is easily 
procured in most cases, and we are quite confident that we have never 
known it do harm, though we have used it in almost every case. The 
patient should be kept in the bath some ten, fifteen, or twenty minutes, 
or until the convulsive movements cease ; when taken out it is most 
convenient, and at the same time useful, to envelop it in a small^ light 
blanket, or flannel, for a short time, before the clothes are readjusted. 

In cases where the attack of eclampsia is limited to a single convul- 
sive seizure, we rarely have an opportunity' of instituting any treat- 
ment for the paroxysm itself, since it is usually over before we reach 
the patient. In such instances, bloodletting is unnecessary. If, how- 
ever, the opportunity offers, and if the convulsion occur in a strong and 
vigorous subject; if it be violent, and accompanied by a deep red, or 
yet more by a livid flush of the face, and distension of the veins of the 
head and neck; if it last more than a few minutes, or is repeated after 
short intervals of quiet, we would, without hesitation, recommend the 
use of bloodletting . The detraction of blood is called for, in our opinion, 
for the same reasons as in puerperal convulsions, and indeed in every 
violent convulsive attack, — to save the nervous centres from the effects 
of the paroxysm, which are, in all severe cases, excessive congestion, 
and, in some, fatal effusions. There are, however, many cases, in which 
we would not advise depletion; as, for instance, those in which the con- 
vulsion depends upon an ansemic condition, and in which it is contrain- 
dicated by a naturally feeble, or by a debilitated state of the constitu- 
tion ; those in which it is clearly unnecessary, from the slight severity or 
short duration of the attack ; or those which occur in the course of other 
diseases, and particularly at their termination, and in which a resort to 
it is rendered evidently improper by the circumstances of the concomi- 
tant affection. The quantity of blood to be taken, and the method, 
must depend on the circumstances of the case. We must be guided as 
to the quantity by the age and constitution of the patient, the violence 
and duration of the paroxysm, and the cause of the attack. In a strong, 
hearty child, two or three years of age, in whom the attack is violent, 
and produced by some cause not likely to continue long in action and 
thereby exhaust the strength, we may take from two to four ounces at 



552 ECLAMPSIA. 

the first bleeding; and should this fail to exert an influence upon the 
paroxysm, a rather smaller quantity maybe taken in one or two hours 
afterwards. In younger children, and those who are somewhat feeble 
or delicate, the amount drawn ought to be less. Usually speaking, 
venesection is to be preferred; but when a general bleeding cannot, 
from any cause, be employed, we may resort to cups and leeches to the 
temples or back of the neck, or, as advised by some of the French 
writers, to more distant parts. 

We believe it is useful in all cases of essential and sympathetic con- 
vulsions, which resist the employment of a warm bath and bleeding, 
and also when bleeding is not resorted to, to make use of an emetic of 
some kind. The act of vomiting alone is often sufficient to break up a 
paroxysm of convulsions which has resisted various other means. This 
we learned first from the advice of an old and experienced practitioner, 
who was in the habit of employing emetics in all cases of eclampsia of 
children, and we have since seen it tested on numerous occasions. Dr. 
Hall recommends the induction of vomiting in the treatment of the 
paroxysm of the croup-like convulsion or laryngismus stridulus, and as 
a means of prevention in epilepsy. In the former he employs irritation 
of the fauces by tickling with a feather; in the latter, ipecacuanha. He 
says that a new mode of action is induced in the true spinal system by 
the act of vomiting, so that the disposition to closure of the larjmx, and 
explanatory efforts, is exchanged for sudden acts of inspiration. The 
emetic which we employ is ipecacuanha. The employment of emetics 
is generally advisable, even when there is no evidence that the attack 
is due to the presence of undigested or irritating substances in the 
stomach, since in cases of sudden eclampsia the cause is so frequently 
some gastric irritation. Of course, when there is special reason to sus- 
pect the presence of such a condition, the indication for the administra- 
tion of an emetic is even more positive. 

In addition to warm baths, bleeding, and emetics, cold applications to 
the head will be found proper and useful in nearly all cases which are 
of any considerable violence. Their use would be improper, however, 
when the surface is pale, the features contracted, and the pulse small 
and feeble ; but whenever the skin, especially that of the head, is deeply 
colored and turgid^ and the pulse full and strong, they ought to be em- 
ployed from the beginning. While the child is in the bath, its head 
may be wrapped in a cloth wet with ice-water; or, after it has been re- 
moved, cold water may be poured from pitchers or a tea- kettle upon the 
same part. If the latter is done, enough should be employed to prevent 
the sudden reaction which inevitably takes place when but a small 
quantity is used. During the after-treatment of the case, the cold ap- 
plications ought to be continued so long as the head remains unnatu- 
rally heated. 

The administration of & purgative dose is proper and useful in most 
cases of convulsions; particularly when it is found upon inquiry that 
the child has been constipated prior to the attack; when it is suspected 
that the bowels may contain crude food or some foreign body; when it 



TREATMENT. 553 

is desirable to produce an evacuant eifeet in a strong plethoric child, 
or a derivative action from the brain, and when the attack is attended 
Avith violent determination of blood towards that organ. The best 
purgative in severe cases occurring in hearty children is calomel. It is 
advantageous because of its easy administration, its speedy operation, 
and the powerful sedative influence which it exerts upon the whole 
economy. The dose should be from three to six grains, according to 
the age. It ought to be followed in one or two hours by some other 
cathartic, which may be either castor-oil, rhubarb, jalap, or salts. The 
best of all is castor-oil if it can be given. When the attack is slight or 
the patient weak and delicate, castor-oil is particularly applicable, as it 
operates with so little irritation to the intestine, or we may employ a 
mixture of castor-oil and spiced syrup of rhubarb. Whatever the 
remedy may be, it should be given only in such quantity as to pro- 
duce complete evacuation of the bowels and a moderate derivation 
upon those organs, without the risk of occasioning a degree of irritation 
sufficient to increase the disturbance of the nervous system already ex- 
isting. 

Id many, indeed, in most cases of eclampsia it will be found that 
purgative eneriiata are of great service. They may be administered 
immediately before or after the bath, and not unfrequently have the 
effect of stopping the paroxysm. They may consist of water holding 
in suspension or solution castile soap, common salt, molasses, castor-oil, 
sweet-oil, or spirit of turpentine. If the first fails to operate in ten or 
fifteen minutes, another or even a third ought to be given. 

Bevulsives are of the utmost importance in the treatment of convul- 
sions. They should be employed from the very first, or immediately 
after the use of the bath. In slight attacks, they alone are often suffi- 
cient to suspend the paroxysm, or at least the fit often ceases under 
their use. Mustard is the most useful and convenient form of applica- 
tion in the great majority of cases. It may be used either in the form 
of sinapisms, which are to be shifted from place to place, or in that of 
the foot-bath. When sinapisms are used, they should always be covered 
with gauze or fine muslin, to avoid the danger of leaving any of the 
mustard upon the skin after they are taken ofP. We once saw very 
bad ulcerations upon the feet of a child from the neglect of this precau- 
tion. In the hurry and bustle of the moment, the feet were not washed 
when the plasters were removed, and the mustard that remained pro- 
duced vesications which ulcerated. In obstinate attacks, the revulsives 
ought to be reapplied from time to time, taking care to shift their po- 
sition in order to avoid vesication. 

Antispasmodics are highly recommended by some writers upon the 
disease, and particularly by M. Brachet, who appears to have used with 
excellent effect the oxide of zinc in combination with extract of hyos- 
cyamus. We have had but little experience in regard to their use, but 
confess ourselves indisposed to resort to them except after the employ- 
ment of the means already detailed; during the intervals between the 



554 ECLAMPSIA. 

fits, when these occur from time to time; and as a means of prevention 
in children threatened with the disease. There can be no doubt, from 
the evidence adduced in regard to their effects, and from what we have 
ourselves seen of the influence exerted by valerian upon the convulsive 
phenomena of acute cerebral diseases, that they have a considerable 
power of allaying the disorder of the locomotive apparatus present in 
all convulsive affections. As a means of prevention, therefore, as adju- 
vants to other remedies, and in children of very nervous, irritable tem- 
perament, and delicate constitution, in whom it is improper to use the 
more powerful agents already detailed, we would advise a recourse to 
substances of this kind. The ones most highly recommended are vale- 
rian, oxide of zinc, assafoetida, and camphor. Of these, valerian or 
assafoetida are the ones we have usually employed. Yalerian is best 
given in the form of the fluid extract, of which from ten to twenty 
drops may be administered in water, to a child two years old, every 
half hour or hour, until several doses have been exhibited, after which 
it ought to be suspended for awhile or given in smaller quantity. 
Assafoetida is best given in the form of emulsion, half a teaspoonful 
being administered hy the mouth, or one or two teaspoonfuls mixed 
with a little warm water may be thrown from time to time into the 
rectum. M. Brachet gives the oxide of zinc in combination with ex- 
tract of hyoscyamus, to the amount of at least two grains of the former 
and four of the latter in twenty-four hours, divided into four, eight, or 
twelve doses. A dose was given every two or three hours, and when 
the symptoms were very violent, the first two or three were repeated 
at much shorter intervals. He sa^-s, speaking of this remedy {Traite 
Prat, des Convulsions dans VEnfance, deux, edit., p. 402-3), " I always 
found it to produce quiet; but whilst the cause remained, the quiet 
was only momentary, and the remedy seemed to have produced no 
effect. . . . This remedy does not destroy the cause (of the convulsion), 
but it allows time to treat it by calming the nervous erethism." 

Opium is a remedy which requires much care and discrimination in 
its employment, but which, in certain conditions of the disease, is of 
the greatest service. It should not generally be given while there re- 
main any evidences of considerable determination of blood to the brain, 
but when this condition does not exist, or after it has been removed by 
bloodletting and revulsives, opium proves very useful in allaying irrita- 
bility and restlessness, which themselves seem to keep up a disposition 
to a return or continuance of the convulsive phenomena. Somnolence 
also, and still more, coma, likewise contraindicate the use of opium. 
Dr. Eberle thinks he has seen much advantage from frictions over the 
spinal region with a mixture of equal parts of oil of amber, laudanum, 
and spirit of camphor, particularly in very young infants. 

Chloroform has been highly recommended in the essential convulsions 
of children, by Sir J. Y. Simpson {Edin. Med. Jour., June, 1858), and is 
favorably spoken of by both West and Trousseau. It should be used 
when the fits are violent and recur frequently, and do not yield to any 
of the remedies previously mentioned. By careful administration, anses- 



TREATMENT. 655 

thesia may be prolonged for many hours, though, as Simpson recom- 
mends, it should be allowed to partial!}^ pass off every two or three 
hours for the purpose of feeding the child. It has been employed in 
numerous cases with the effect of arresting the convulsions, and in no 
instance has any unfavorable result been observed to follow its use. 

Bromide of potassium, which has of late been so successfully employed 
in the treatment of almost all forms of convulsion, may be given with 
advantage, especially W'hen the convulsions continue to recur at more 
or less regular intervals. It may be given in doses of one or two 
grains, three or four times daily, from the age of six months to one 
year, with an additional grain for every year. 

Ice. — In a case of severe convulsions in a new-born infant recorded 
by Dr. EUwood Wilson (Phila. Med. Times, :N'ov. 1, 1873, p. 65), the 
introduction of a small conical piece of ice into the rectum immediately 
arrested the paroxysm each time. 

We shall here conclude our remarks upon the general treatment of 
eclampsia, and proceed to make some observations on the conduct to 
be pursued under particular circumstances. 

It is always hfghly important for the direction of the treatment, to 
discover the cause of the attack. This is sometimes very easy, while 
in other instances it is exceedingly difficult, and not unfrequently im- 
possible. If the attack occur in the course of some acute disease, as 
pneumonia, catarrh, angina, enteritis, or dysentery, or during the prog- 
ress of one of the eruptive diseases, the diagnosis of the case is, as a 
general rule, very easy. If, on the contrary, it occurs at the com- 
mencement of one of these affections, the diagnosis will be much more 
difficult, unless indeed the symptoms of the concomitant disease have 
already declared themselves, or should do so very soon after the con- 
vulsion. The treatment in such cases should be that laid down in our 
general remarks, modified, however, by the requirements of the par- 
ticular disease during the course of which the eclampsia occurs. 

When the attack occurs suddenly in a child previously in good health, 
or who had been merely slightly ailing for a few hours, the detection 
of the cause is still more difficult. The most probable causes under 
such circumstances are, however, dentition, indigestion, intestinal dis- 
order, or the approach of an acute general or local disease. It is easy 
to determine by inquiry of the attendants, and by examination of the 
mouth, whether the child is teething or not. As a general rule, the 
convulsions which dej)end solely on the process of dentition, are slight, 
and last but a short time. In all the instances that we have seen, in 
which such was the only cause to be detected, the attack w^as of this 
nature. The treatment in such instances is to lance the gums, if they 
are swelled and inflamed over the advancing teeth ; to use w^arm baths, 
and to administer purgative and then antispasmodic enemata. These 
simple means will seldom fail w^hen eclampsia depends on the process 
of dentition alone. But when, on the contrarj^, there is present indi- 
gestion, intestinal accumulations, or enteritis, as often happens during 
dentition, the case becomes more serious, and requires in addition to 



556 ECLAMPSIA. 

the treatment above described, one directed to the particular coexisting 
morbid condition. 

The existence of indigestion as the cause of the attack, can be dis- 
covered only by ascertaining with great care the diet of the child 
during the previous days. If it appear that something of an indigest- 
ible nature has been eaten within a short time, and if, at the same time, 
it be impossible to detect any more evident or probable cause for the 
attack, we should have a right to conclude that it depends upon indi- 
gestion. Under these circumstances the proper treatment is the im.- 
mediate use of the warm bath, and the earliest possible administration 
of an emetic of ipecacuanha. The operation of the emetic may often 
be hastened by tickling the fauces with a quill. 

The presence of intestinal accumulations as the cause of the par- 
oxysms may be inferred, when it is found upon inquiry that the patient 
has been constipated for some days, or that the stools have been scanty 
and hard, or scanty and very offensive ; when the abdomen is distended 
and hard, and the distension is ascertained by palpation and percus- 
sion, not to be merely tympany; and, lastly, when there is no more 
evident cause for the attack. In such a case the particular treatment 
is the use of purgatives and enemata, in addition to the other means 
detailed. 

If the child presents the symptoms of dyspepsia and malnutrition, 
associated with anaemia, and the convulsions recur durins; a lono- 
period, the most scrupulous care must be taken to secure a nutritious, 
digestible diet, combined with the use of tonics and iron. 

The dependency of the attack on the approach or commencement of 
some acute general or local disease, can be inferred only from a very 
careful examination of the antecedent and present phenomena of the 
case. One of these may be suspected as the cause when we can account 
for the occurrence of the convulsion on no more reasonable supposi- 
tion ; when neither dentition, indigestion, nor intestinal irritation exist. 
It is scarcely likely that a convulsion could be occasioned by s^nj of 
the acute thoracic or abdominal affections, unless the disease had 
already gone far enough to allow a careful examination of the different 
rational and physical symptoms, to determine its existence. Perhaps 
the most difficult cases to diagnosticate, are those which occur at the 
beginning of the eruptive fevers. Even here, however, a careful search 
for the prodromic symptoms of the disease, a watchful observance of 
the condition of the patient in and after the paroxysm, will generally 
lead to a correct opinion within a few hours, or after a day, and some- 
times at the moment of the attack. Of the eruptive diseases, scarlet 
fever is much the most apt to be accompanied by convulsions at the 
onset, and in that disease the remarkable rapidity and activity of the 
pulse, the state of the fauces, the heat of skin, and early appearance of 
the eruption, will generally enable us to understand the cause of the 
convulsion at a very early period. 

The treatment of sympathetic eclampsia depending on acute thoracic 
or abdominal disease, should be that which is proper for the particular 



LARYNaiSMUS STRIDULUS. 657 

malady which they complicate, with the addition of warm baths, re- 
vulsives, antispasmodics, and, after depletion, of opium, in the form of 
Dover's powder combined with nitre. The management of the convul- 
sions which complicate the eruptive fevers, will be specially treated of 
in the articles on those maladies. 



AETICLE yil. 



LARYNGISMUS STRIDULUS. 



Definition; Synonyms; Frequency.— Laryngismus stridulus belongs 
to the class of neuroses. It is characterized by crowing inspirations, 
or by momentary suspensions of the act of respiration; these attacks 
occur suddenly, and at irregular intervals, are of short duration, cease 
suddenly, and are unaccompanied by cough, or other signs of irritation 
of the larynx. If the disease progress, it becomes associated with other 
convulsive symptoms, as strabismus, distortion of the face, carpopedal 
spasms, or general convulsions. 

It is "the peculiar species of convulsion" of Dr. John Clarke; the in- 
ward fits of Underwood; the spasm of the glottis of Marsh, West, and 
Yogel; the laryngismus stridulus of Good; the croup-like convulsion of 
Dr. Marshall Hall; child-crowing; the spasme de la glotte of some of 
the French writers; one form of the internal convulsion of MM. Trous- 
seau and PidouXj of MM. Eilliet and Barthez,and of J, L. Smith; and the 
thymic asthma of some of the German authors. It is described by 
Eberle under the title of carpopedal spasms. 

The frequency of the disease seems to vary in different countries. 
In France it would appear to be somewhat rare. MM. Eilliet and Bar- 
thez (2eme edit.) speak of having seen nine cases. At the time of pub- 
lication of their first edition, they had met with only one case, and 
then stated that they were acquainted with only one other, published by 
M. Constant in the Bulletin de Therapevtique. M. Blache (article 'Nev- 
rose du Lar^ nx, Diet, de Med., t. xvii, p. 590) adverts very cursorily to 
one case. M. Yalleix (Guide du Med, Prat,, art. Asthme Thymique) 
doubts its existence as a distinct disease. In Germany, on the con- 
trary, it would seem to be a rather frequent disease. In England it 
cannot be very infrequent, since Merriman says it is by no means un- 
common. Copland {Stridulous Laryngic Suffocation in Children, Diet, of 
Frac.Med,) speaks of numerous cases that he has seen, and states that 
he has had as many as three under treatment at the same time. Ley 
speaks of having met with considerably above twenty cases. Dr. 
Marshall Hall remarks that "within the short space of one month, I 
have seen five cases of croup-like convulsion." Dr. Charles West (4th 
edit., p. 162) mentions thirty-seven cases of which he has preserved 



558 LARYNGISMUS STRIDULUS. 

some record. The statements of more recent English writers indicate 
that it continues to be of quite frequent occurrence. 

We do not think it is a common disease in Philadelphia, though it is 
certainly not extremely rare, since we have either seen ourselves or 
heard of the occurrence of a comparatively large number of cases. 

Predisposing Causes. — Age. — It is generally acknowledged that the 
disease occurs most frequently during the period of the first dentition, 
though it has been known to occur as late as six or seven years of age. 
Of 30 cases selected indifferently from our practice and from authors 
in which the age is given, 13 were six months or less of age, 11 between 
six months and a year, 4 between one and two years of age, 1 of two, 
and 1 of four years of age; so that of the 30, 24 were under one year. 
It is evident, therefore, so far as these cases go, that the majority 
occur within the first, and very few after the second year. 

Of the 37 cases mentioned by Dr. West, 31 occurred in children be- 
tween six months and two years of age. All the cases seen by MM. 
Eilliet and Barthez were in children under two years old. Those au- 
thors state that the seven subjects observed by M. Herard were more 
than two years of age, and that two of them were between three and 
four years old. From the statements made by authors in general, it 
would seem to be most frequent between the ages of three weeks and 
eighteen months. It has been known, however, in one very rare in- 
stance, to occur as late as seven years of age. 

Sex. — It is most frequent in the male sex. Of 50 cases (45 from 
authors, and 5 by ourselves), 39 occurred in boys, and 11 in girls. MM. 
Eilliet and Barthez state that of 16 cases observed by themselves and 
by M. Herard, 12 occurred in boys, and 4 in girls; of 183 cases collected 
by M. Lorent, in which the sex was noted, 125 occurred in boys, and 
58 in girls. 

Constitution. — It seems established that it sometimes occurs in the 
most healthy and vigorous subjects, being then probably dependent upon 
reflex nervous irritation. It is, however, far most frequently met 
with in children who are delicate and feeble, and especially in those of 
scrofulous or rickety constitutions. The very frequent association of 
rachitis with laryngismus has been more and more prominently devel- 
oped during the past few years. Some high authorities, since the pub- 
lication of Elsasser's researches, in 1843, have even asserted that this 
connection is a constant one, and that laryngismus is essentially depend- 
ent upon craniotabes or rachitic disease of the skull. There are certain 
cases in our own experience, and others which are reported by careful 
observers, which do not allow us at present to admit that this connec- 
tion is an invariable one, but there can be no doufot that in the great 
majority of cases laryngismus occurs in rachitic children, and particu- 
larly in those who have craniotabes, or ''soft spots" in the occiput. 
It not unfrequently attacks several children in a family. Ley quotes 
four instances from other writers, in which three children in each fam- 
ily had the disease, and in one all three died. He states that his own 
experience fully confirms this fact. 



NATURE — CAUSES. 559 

MM. Eilliet and Barthez (2eme ^dit., note, t. ii, p. 527) state that 
Davies and Henrich have met witli four, and Torgord five children of 
the same family affected with the disease. They quote from Eeid the 
curious fact that Powell saw one family of thirteen children, not one 
of which escaped the disease. 

Amongst the causes of the disease, in addition to those already men- 
tioned, must not be forgotten dentition and improper food. These two 
are, indeed, probably the most influential of all in the production of 
the complaint. The age at Avhich it occurs most frequently, the last 
half of the first, and the first half of the second year, the very period 
during which the process of dentition is most active, would alone go 
far to show that this must constitute one of its most powerful predis- 
posing^ if not exciting, causes. The opinions of writers on this point 
are also conclusive as to the great influence of this vital process. Im- 
proper food, and especially early weaning, and the attempt to bring 
the child up by hand, is clearly a potent predisposing cause of the dis- 
ease. This has been clearly shown in the cases that have come under 
our own observation, and especially in one in which contraction with 
rigidity followed the symptoms of laryngismus. The details of this case 
will be found appended to the article on contracture. Dr. James Reid, 
in an excellent work on the disease (see Brit, and For. Med.-Chirurg. 
Rev., July, 1849, p. 163), gives the following conclusions as to its eti- 
ology: "1. That for the occurrence of this complaint, the cerebro- 
spinal system is required to be in a peculiarly excitable state, which 
then acts as a predisposing cause. The period of teething is the most 
likely to produce this condition. 2, That during this irritable state of 
the nervous centres, the two most frequent (and in the majority of in- 
stances the combined) causes are the improper description of food which 
is administered to the infant, and the impure and irritating atmosphere 
which it breathes." It must not be forgotten that while in some cases 
these causes act in producing laryngismus by reflex irritation from the 
gums or mucous membrane of the alimentary canal upon a weak and 
over-sensitive nervous system; in other cases, the laryngismus is essen- 
tially connected with rickets,, which has been induced by improper 
feeding. 

Nature and Exciting Causes; Forms. — Much difference of opinion 
has prevailed in regard to the nature and exciting causes of laryngis- 
mus stridulus since the disease has attracted the particular notice of 
the profession. Kopp and other German authors ascribe it to compres- 
sion of the respiratory organs by an enlarged thymus gland, while 
others of that nation, and some of the English and French writers, class 
it amongst the neuroses. Dr. Hugh Ley supposed it to depend on com- 
pression of the par vagum nerves by enlarged cervical and bronchial 
glands. Dr. Marshall Hall considers it to be a disease of the reflex 
system of nerves. Amongst the French writers, MM. Eilliet and Bar- 
thez regard it as a neurosis; Yalleix and Trousseau treat of it as one 
form of convulsions in children ; Blache {Diet, de Med., t. xvii, p. 584) 
speaks of it as a neurosis of the larynx, which may be either sympto- 



560 LARYNGISMUS STRIDULUS. 

matic or idiopathic. Many recent -authors, as already stated, are dis- 
posed to regard it as dependent upon the irritation of the brain, due to 
the existence of craniotabes. 

Before examining in detail the different opinions quoted above, which 
we propose doing, we will refer to the anatomical appearances of the 
malady. 

The mucous membrane of the air-passages, as a general rale, is found 
perfectly healthy, presenting neither redness, inflammatory swelling, 
oedema, nor accidental products of any kind. The lungs are usually of 
the natural color and density, and crepitant. M. Herard {Bib. du Med. 
Prat., t. V, pp. 319, 320) observed that in several autopsies made by 
himself, they always presented one marked change from their natural 
condition, however, which was a very high degree of emphysema, more 
general and strongly marked than in any other disease. This alteration 
is believed to depend, as it does in hooping-cough, upon the impediment 
to respiration which exists during the disease. MM. Eilliet and Bar- 
thez state, however, that emphysema was not present in any of their 
autopsies. 

The heart and great vessels of the thorax often, but not always, con- 
tained more blood than usual, as in asphyxia. 

M. Herard states that he has made very minute researches in regard 
to the condition of the nervous system, examining the brain and spinal 
marrow, the pneumogastric, recurrent, and diaphragmatic nerves, and 
those of the extremities even, to their terminations, without, however, 
finding important lesions in any case. He excepts only serous effusion 
in small quantity, and evidently consecutive, in the ventricles and par- 
ticularly in the membranes of the brain, and slight venous congestion 
of the same kind. The tissues of the brain and spinal marrow retained 
their ordinary consistence, and presented neither redness nor soften- 
ing. 

The condition of the pneumogastric nerves has, however, been vari- 
ously reported by different authors, some having found them softened, 
others indurated. 

In some cases tuberculosis of the lungs or bronchial glands, has been 
observed. But as these, as well as all the other lesions mentioned, are 
not constant, they cannot be regarded as characteristic. In many in- 
stances more or less marked evidences of rickets are discovered upon 
the bones of the cranium, the ribs, or the long bones of the extremities. 

We will now examine as succinctly as possible the different opinions 
which have been advocated in regard to the causes of larj^ngismus strid- 
ulus. These may be classed, it seems to us, under four heads. 1. En- 
largement of the thymus gland. 2. Enlargement of the cervical and 
bronchial glands. 3. Organic disease of the cerebro-spinal axis. 4. That 
which regards it as a simple neurosis, without appreciable anatomical 
alterations. 

1. Enlargement of the Thymus Gland. — That the disease is in some 
cases coincident with, if not dependent upon, this condition, is proved 
by the observations of Kopp, Hirsch, Haugsted, Kyll, and others. Hasse 



NATURE — CAUSES. 561 

[PathoJ. Anaf., Syden. Soc. Ed., p. 3S4) says there can be little doubt 
that it sometimes depends upon this cause. 

It appears to us^ however, that it has been clearly shown by M. He- 
rard [loc. cit., p. 320, 321), that the disease is entirely independent of any 
alteration of the thymus. That observer found that in six children 
between two and four years old, dying of the affection, the gland weighed 
between half a drachm and a drachm in five, and four drachms and two 
scruples in the sixth. These cases alone show that the size of the gland 
varies greatly in different subjects attacked with the disease. M. Herard 
has examined the gland, with a view to the elucidationof this point, in 
sixty children dj'ing with various diseases, between two and four years 
of age (the age of those who had died of the disease under consideration). 
In fifty he found that it presented the same arrangement, color, density, 
and weight, as in those who had perished with laryngismus stridulus. 

All of these subjects exhibited the same aspect; they were pale, thin, 
and most of them exhausted by diarrhoea. In ten of the sixty the gland 
was much more voluminous, weighing from two to tw^o and a half or 
five drachms, and in one instance an ounce and a quarter. The ten 
subjects upon which these observations were made, died of different 
diseases, croup, acute laryngitis, asthma, meningitis, and varioloid. All 
exhibited the appearances of strong and vigorous health; the one which 
presented the largest gland was very fat, and so robust, that, though 
only twenty-two months old, he looked to be three or four years. It 
appears to result therefore from these researches, that the gland is 
liable to great variations of -size, and that its size bears a very exact 
proportion to the force of the child, being small in those w^ho are 
slightly developed, or emaciated by chronic disease, and voluminous in 
those who are vigorously constituted, or w^ho have died of acute dis- 
eases. 

That the disease does not depend, at least in all cases, on this cause, 
is shown also by Haugsted {Arch, de Med., t. xxxiii, 1833, p. Ill), who 
reports the case of a girl, seven years old^ in whom the gland weighed 
five ounces, and measured four inches long, and one and a half in thick- 
ness, without its occasioning the least difficulty of breathing of any 
kind. That it occurs in children in whom the gland is very small, is 
shown also by Caspar! and Pagenstecher (g^uoted by Hasse, loc. cit.). 

2. Enlargement of the Cervical and Bronchial Glands. — This condition 
as a cause of the disease, so strongly advocated by Dr. Ley, and adopted 
upon his authority by Kyll and Hasse, would seem from certain facts 
and arguments to be of doubtful agency. 

Thus, Mr. Wakely (quoted by Kerr) states that " he possesses more 
than one ease of tubercular affection in children, where the pneumogas- 
tric nerve has been completely flattened by the pressure of tubercles, 
without giving rise to any remarkable disturbance of the function of 
respiration/' Dr. Hall doubts the correctness of this explanation of 
the phenomena of the disease, and says that if the contiguity of en- 
larged glands with the pneumogastric nerve have any effect, it is by 

36 



562 LARYNGISMUS STRIDULUS. 

their action upon it as an incident excitor, and not as a motor or mus- 
cular nerve. 

3. Organic Disease of the Cerebrospinal Axis. — That it may depend on 
this cause is proved by a case mentioned by Dr. Coley (O/i Infants and 
Children, BelVs edition,]). 226). v^^ho states that in a fatal instance which 
occurred in his own family, the only morbid appearance found on dis- 
section was a large exostosis growing on the inner surface of the occi- 
put, which compressed the cerebellum and produced chronic inflamma- 
tion of the dura mater. No disease was discoverable either in the 
cervical or thoracic glands. Dr. Kyll (Arch. Gen de Med., t. xiv, 1837, 
p. 94) quotes a case from Dr. Corrigan^ of Dublin, which had lasted 
three months, in spite of calomel, emetics, and antispasmodics. Atten- 
tion was called by chance to the spinal column, when it was discovered 
that pressure over the third and fourth cervical vertebrae was very 
painful, and produced loud cries from the child. Two applications of 
four leeches, at an interval of two days, to that point, removed all the 
symptoms, and the child recovered perfectly. 

Dr. M. Hall {^Diseases and Derangements of the JServous System, 1841, 
p. 99) states that the crowing inspiration may arise from affections of 
the centre of the excito-motory system. He quotes a case related to 
him by Mr. Evans, of Hampstead, of spina bifida, in which '"there was 
a croup-like convulsion whenever the little patient turned so as to press 
upon the tumor." He states, moreover, that he found induration of 
the medulla oblongata in one case of the disease. 

Dr. West has also noticed occasional attacks of laryngismus stridulus 
in chronic hydrocephalus, occurring even before much enlargement of 
the head had appeared. 

4. That it is a Neurosis. — We have seen that in very few cases of 
larj^ngismus there is actual.organic disease of the brain or spinal cord. 
It is necessary, therefore, to regard it as most frequently a purely spas- 
modic nervous affection dependent upon irritation of certain parts of 
the nervous system which are directly or indirectly connected with the 
muscles of the glottis. Almost all recent authorities concur in the main 
with this opinion. 

That it is not always, however, a neurosis, is also shown by the cases 
quoted under the first head from Drs. Hall and Coley, and by those in 
which the disease is accompanied from the first by symptoms of inflam- 
mation or congestion of the brain. 

It has now been shown that the causes of the disease are exceedingly 
variable and uncertain, and that any opinion which asserts its depend- 
ence on one invariable and constant cause is untenable. We must, 
therefore, seek some explanation which shall reconcile, as far as pos- 
sible, the facts related above, and harmonize the various opinions ex- 
pressed by the authors quoted. 

It seems to us that the explanation given by Dr. Hall (loc. cit.), is the 
only one which accounts satisfactorily, for the phenomena of the dis- 
ease, and reconciles the contradictory accounts of its nature and causes 
brought forward. Dr. Hall regards it as an affection of the excito-motory 



NATURE — CAUSES. 563 

or true spinal system of nerves, producing in mild cases partial closure 
of the glottis, and difficult inspirations, while in more severe cases the 
spasmodic disposition extends to other parts of the body, — to the eye- 
balls, and to the flexors of the fingers and toes. We have already 
alluded to his theory that in very violent attacks of laryngismus, where 
the glottis is entirely shut, the suspension of respiration produces con- 
gestion of the nervous centres and 'general convulsions. As already 
stated, however, this theorj" has not been accepted, and we regard the 
occasional occurrence of general convulsions in connection with laryn- 
gismus stridulus, as one proof that this latter affection is merely a par- 
tial and imperfectly developed convulsion. 

The causes may be either centric, seated in the nervous centres, or 
centripetal, in the excitor or incident nerves. In the great majority of 
cases, the causes are centripetal, consisting of various morbid condi- 
tions situated at the peripheral extremities of the nerves, which become 
causes in consequence of the irritation they establish in the nerve-ex- 
tremities : this irritation is transmitted to the nervous centres, and 
thence reflected through the various efferent or motor nerves to the 
different portions of the muscular apparatus affected in the disease, the 
larynx, face, extremities, and lastly, in severe cases, the whole body. 
The principal causes of this class are dental irritation occurring during 
dentition; gastric irritation, arising from excessive or improper food ; 
intestinal irritation from constipation, intestinal disorder or catharsis; 
and perhaps the pressure of an enlarged thymus or of enlarged cervical 
or bronchial glands. 

The centric class of causes includes such as are seated in the nervous 
centres. These are much less common than the former class, and give 
rise to a vastly more dangerous and intractable form of the disease. 
Foremost among them, according to recent observations, must be placed 
the development of " soft spots" in the occipital bone in connection 
with rickets, which allows pressure upon the back of the head to in- 
duce irritation of the brain. There are also different morbid conditions 
of the brain and spinal marrow, as inflammation, congestion, and effu- 
sion, which appear to have occasionally proved the cause of laryngis- 
mus. That such causes sometimes produce the disease is shown by the 
case of exostosis already quoted from Coley, that of spinal irritation 
from Kyll, that of Dr. Hall, in which he found induration of the medulla 
oblongata, and the one of spina bifida reported to Dr. Hall by Mr. 
Evans. In the latter case the tumor was seated on the loins. Mr. E. 
proposed to treat it by compression, but on making the attempt found 
that it was followed immediately " by the affection described by Dr. J. 
Clarke" {Hall^ loc. cit., p. 144). Other centric causes, which have been 
ascribed in some rare instances, are passion, vexation, fright, contra- 
diction, &c., &c. 

This theory of the nature of the disease likewise accounts for the 
varying character of the convulsive symptoms. The laryngeal spasm, 
from which the disease derives its name, does not constitute the whole 
malady; it is only one of the symptoms, though the principal one, and 



564 LARYNGISMUS STRIDULUS. 

that by which it is particular!}" characterized. The other convulsive 
phenomena, which generally occur onl}^ in severe attacks, or after the 
disease has continued for some time, are distortion of the face, strabis- 
mus, carpopedal spasms, and general convulsions. The hydrocephalic 
symptoms which occur towards the termination of such cases, and the 
serous eflTasion within the cranium found after death, are, it ought to 
be recollected, often the consequences of the congestion of the brain 
and asphyxia, w^hich take place during the more or less complete clos- 
ure of the larynx. 

Symptoms; Course; Duration. — Laryngismus stridulus begins sud- 
denly with a paroxysm of difficult respiration. The larynx is con- 
tracted spasmodically, and the entrance of air into the lungs is either 
prevented or impeded. In most cases the closure of the larynx is only 
partial, and the respiratory movement continues, but is accompanied 
by prolonged and difficult inspirations, which give rise to the crowing 
or stridulous sound, whence the disease derives its name. The crowding 
sound is generally heard several times in each paroxysm, owing to the 
repeated but only partially successful attempts at inspiration ; while 
in very violent cases it occurs only at the beginning and end of the ac- 
cession, the respiration being entirely suspended in the middle period. 
At the same time the child presents an appearance of great distress. 
The body is thrown forcibly backwards, the eyes are fixed and staring, 
the nostrils dilated, and the whole countenance indicative of great anx- 
iety. If the paroxysm continues many seconds, the face becomes blu- 
ish, the extremities cold, and the fingers and toes contracted. After a 
few seconds, or a minute, or even longer, the spasm of the larynx 
ceases; a loud, full inspiration takes place; a fit of crying generally 
follows, and the child either very soon regains its usual spirits, or, if 
the paroxysm have been very severe, seems weak, languid, and drowsy, 
and returns more slowly to its ordinary condition. Between the par- 
oxysms the child may seem perfectly well so far as concerns the char- 
acter of the respiration, but it almost alwaj^s exhibits the symptoms of 
some derangement of the general health, or, in other words, of the 
morbid condition which is the ultimate cause of the laryngeal spasm. 

The paroxysms are most apt to occur during sleep, or as the child is 
waking. They occur spontaneously, and are brought on by fretting or 
crying, coughing, fright, contrarieties, deglutition, bj^ the sudden ap- 
plication of cold, and other sudden impressions. At the commence- 
ment of the disease they recur at rare intervals, and often attract little 
notice; but, as the case progresses, they become more frequent, and 
may amount to twenty or thirty in the daj^, according to Kerr. They 
sometimes cease entirely for some weeks, or even months, and then re- 
commence. In a case attended by one of ourselves (reported in the 
Am. Jour. Med. .Sci., April, 1847, p. 287) , the attacks lasted eighteen 
days, occurring sometimes two or three times in an hour, and sometimes 
much less frequently. The child then recovered entirely for a period 
of seven months, when the disease returned, and after continuing for 
five days, caused the death of the child in one of the paroxysms. 



SYMPTOMS. 565 

If the disease continues to progress, it almost always becomes asso- 
ciated with other spasmodic symptoms. The thumbs are drawn tightly 
into the palms of the hands, and the fingers clasped over them, which 
gives to the back of the hands a swelled and tumid look. At the same 
time the toes are strongly flexed under the feet, and the insteps look 
swelled like the backs of the hands. Sometimes the hands are bent on 
the forearms, and the forearms on the arms. There is often distortion 
of the face. In severe cases, or when the disease has continued for a 
considerable period, epileptiform convulsions make their appearance, 
and generally prove fatal. 

The disease is apyretic in a large majorit}' of cases. When fever 
arises it almost always depends on the condition which has occasioned 
the disordered action of the excito-motory system, or on some acci- 
dental complication. The pulse during the paroxysm is small, corded, 
rapid, and sometimes imperceptible. In the intervals it is natural or 
nearly so. 

Death may occur very early in the disease, or after some weeks, 
months, or according to Kyll, years. Yogel states (ojo. cit.^ p. 272) that 
"sometimes even the very first attack terminates in death, and a seem- 
ingly perfectly healthy child may be carried ofi'in a few seconds." In 
a case quoted by MM. Eilliet and Barthez, death took place at the end 
of three weeks, and in another, in twenty months. 

The duration is very uncertain. It generally, however, lasts several 
months. In one of our own cases it lasted eighteen days, then ceased 
for seven months, returned, and proved fatal in five days. In another 
case, the attacks of spasms returned from time to time, during a period 
of three weeks. In another case, the notes of which were obligingly 
furnished us by our friend Dr. Benedict, and which we shall append to 
this article, it lasted, in connection with contracture, four months and 
a half, and was followed by perfect recovery. 

Other Forms of Internal Convulsions. — We have, for the sake of clear- 
ness, limited ourselves so far in the present article, to cases where the 
spasm is confined to the muscles of the larynx, when the attack might 
be called one of laryngeal convulsion. 

In other cases, however, the spasm may afl'ect, either solely, or in 
conjunction with the larynx, the diaphragm, and the respiratory mus- 
cles of the abdomen and chest, constituting what is termed by some 
authors " internal convulsions.'' The most common form of internal con- 
vulsion as described by Trousseau, '-is characterized by rolling up- 
wards of the eyeballs, by an almost complete loss of consciousness, by 
extreme difficulty or impossibility of deglutition, by irregular respira- 
tion, at times barely perceptible, or free, deep, and blowing, indicating 
that the diaphragm and the respiratory muscles of the abdomen and 
chest are especially afi'ected." 

These internal convulsions may be associated with partial or even 
general convulsions of the face and extremities; more frequently, how- 
ever, they are accompanied by more or less general tonic muscular con- 
traction. 



566 LARYNaiSMUS STRIDULUS. 

In most cases, as indicated in the passage quoted from Trousseau, 
the muscles of the pharynx are involved, and there is marked dyspha- 
gia or utter inability to swallow. 

In some instances, also, the frequency, irregularity, and smallness of 
the pulse, and the irregular and tumultuous character of the action of 
the heart indicate, as pointed out by Eilliet and Earthez {op. cit., 
t. i, p. 510), that the organs of circulation probably share in the convul- 
sion. 

The degree in which the larynx participates in the attack varies 
much in different cases; at times there is no obstacle whatever to the 
entrance or exit of air through its cavity, at others, the spasm of its 
muscles is so extreme that the passage of air is entirely obstructed ; 
whilst in still other cases, of which the one communicated to us by the 
late Prof. Pepper, and quoted at the end of this article, is an example, 
respiration is difficult and accompanied by a stridulous noise. 

The above description a^pplies to those cases of internal convul- 
sions where the convulsion is complete, and presents both the primary 
tonic contraction and the subsequent clonic spasms of the respiratory 
muscles. 

But in other cases, the attack consists merely of a sudden tonic 
spasm of the diaphragm and respiratory muscles of the abdomen and 
chest, followed by a sudden and complete relaxation. The entire sus- 
pension of the respiration during the spasm would of course rapidly 
induce fatal asphyxia, but fortunately the attacks, as we have met 
with them, have usually been so brief as not to cause any dangerous 
symptoms. 

These attacks are popularly known in this country, and were de- 
scribed in the earlier editions of this work, under the title of ^' Holding- 
breath Spells." 

We have met with a considerable number of well-marked cases of 
the affection, and believe it to be of quite common occurrence. It sel- 
dom happens that the physician is consulted in regard to it, as those 
who have charge of children in whom it occurs, almost always ascribe 
it to temper, and think it of but little moment. It appears to be the 
result of a sudden spasm of all the respiratory muscles, so that the 
child ceases for the time to breathe, from which circumstance, no doubt 
it has received its name of " holding-breath spell." There is no strid- 
ulous sound, nor hoarseness of the crj^, nor indeed sound of any kind. 
The face is contracted and bluish, the base of the thorax retracted and 
immovable, and the limbs violently agitated at first, and then stiff; 
after a few seconds, or perhaps a minute in severe cases, the spasm 
yields, the child instantl}' makes a full inspiration, unattended with 
stridulous sound, and generally bursts into a loud fit of crjing, which 
lasts for a few moments, after which the child seems perfectly well, or else 
the attack is followed by excessive paleness, with languor or prostration, 
lasting half an hour or even longer. The attacks recur with variable 
frequency ; there may be several in a day, or but one, or they may occur 
only at intervals of several days. The most frequent cause of the par- 



DIAGNOSIS — PROGNOSIS. 567 

oxjsms is contradiction. They are determined also by fright, pain, and 
crying. They never occur spontaneously, and never during sleep, so 
far as we know. It is to be distinguished from laryngismus stridulus 
by the absence of the crowing sound, by its not occurring spontaneously 
or during sleep, and by the absence of carpopedfil or other spasmodic 
symptoms. It is, we believe, a spasmodic affection of respiration, analo- 
gous to, though not exactly similar to laryngismus stridulus. We have 
never met with it except during the period of the first dentition, and al- 
ways in children of nervous temperament. The cases that we have met 
with all recovered, and in one only did the life of the child seem to be at 
all endangered. In this instance the parox3"sms had recurred very fre- 
quently for eleven months, and on two occasions were terminated by 
slight spasmodic movements of the limbs, lasting only for a few instants, 
and unaccompanied by insensibilit}" or other dangerous symptoms. 
After these attacks the child was removed to the country, where he 
recovered perfectly. 

Diagnosis. — The only disease w^ith which laryngismus stridulus is 
likeh- to be confounded is spasmodic laryngitis, or false croup. From 
this it may readily be distinguished by the absence of catarrhal symp- 
toms, or fever; by the fact that the paroxysms occur indifferently in 
the day or night, and that they are much more frequent; by the dura- 
tion of the paroxysms, w^iich last only a few seconds, or more rarely a 
minute; by the absence of cough or hoarseness of the voice, even 
during the height of the paroxysm; by the occurrence of tonic mus- 
cular spasms, and convulsions ; and finally, by the chronic course of the 
malady : the converse of all of w^hich symptoms exist in spasmodic 
croup. 

Prognosis. — The prognosis of laryngismus stridulus is always serious, 
since even the mildest cases may terminate fatally in any one of the 
paroxysms. It is, however, far from being so dangerous a disease as 
has been supposed by some writers, and amongst others M. Yalleix, 
who states that it is almost always fatal {Guide du Med. Prat., t. i, p. 
564). Of 56 cases collected from Pagenstecher, Hachman, Ley, Kopp, 
Hall, Constant. Eilliet and Barthez, Kyll, and 5 from our own observa- 
tion, making 61 in all, 4 died of intercurrent or consecutive diseases, 
while of the remaining 57, 32 were cured, and 25, or about 43 per cent, 
died of the malady itself. 

MM. Eilliet and Barthez quote from M. Lorent, the translator of Dr. 
Eeid's work, the statement, that of 289 cases collected from various 
writers, 115, or rather more than 39 per cent, proved fatal. 

The prognosis given by the physician ought to depend in great 
measure upon the cause of the malady. When it depends on difficult 
dentition, improper diet, or gastro-intestinal disease, w^iether or not 
connected, as they very frequently are under these circumstances, with 
rickets, the case will in all probability terminate favorably if the proper 
treatment can be, and is, brought to bear against those morbid condi- 
tions; while if it occur under the influence of a centric cause, or of en- 
largement of the cervical or bronchial glands, the prognosis becomes 
much more unpromising. 



568 LARYNGISMUS STRIDULUS. 

Treatment. — If the views taken of the nature of the disease in the 
above remarks be correct, it must be evident that for the treatment to 
offer any considerable chance of success, it must be directed not merely 
to the removal of the spasm of the larynx, which is only a symptom 
and not the whole dis'ease, but to the remedying of the deeper-seated 
cause of the disordered functional action of the excito-motory sj-stem 
of nerves. In this connection it is especially important to search for 
the symptoms of rickets, which we have seen to be so often the primary 
underlying cause of the attacks. 

When the disease seems to immediately depend upon difficult dentition, 
the gnms ought to be carefully watched, and freely scarified, so soon as 
there is the least heat or swelling over the advancing teeth. Dr. Marshall 
Hall deems the use of the gum-lancet one of the most important means 
of treatment we are possessed of, and recommends that the gums should 
be fully divided, " not once, or occasionally, but twice or even thrice 
daily." In another place, he says: " We should lance the gnms freely 
and deeply, over a great part of their extent, daily, or even twice a day, 
and apply a sponge with warm water, so as to encourage the flow of 
blood." He even recommends that in very urgent cases, the lateral as 
well as the more prominent portions of the gum, should be scarified. 
Lancing of the gums is undoubtedly a most important point in the 
treatment of this and other diseases of childhood, connected with den- 
tition. We have long been convinced, however, from personal observa- 
tion, that a resort to this operation merely because the child is passing 
through the period of dentition, is at least useless. We have never 
found it to do any good, unless the teeth are near enough to the sur- 
face to produce manifest swelling, attended with heat and soreness of 
the gums. So long as the gum is hard, insensible, not turgid, and of 
its natural color, and the mouth not hot, cutting has done no good. 

When the disease depends on gastric irritation, the result of an un- 
healthy milk or of artificial diet, or when there are evidences that these 
morbid influences have induced rickets, our attention must be directed 
principally to the removal of these conditions. A wet-nurse ought to 
be procured at once if one can be obtained, and if the child will nurse. 
If this cannot be done the diet must be carefully regulated by the phy- 
sician. Ass's milk or goat's milk ought to be used if they can be pro- 
cured ; if not, we would recommend the gelatin diet prepared as 
recommended at page 338. The proportion of the ingredients must be 
regu^ited by the condition of the stomach. If the digestive power be 
very weak, the proportion of milk must be only a fourth or even a 
sixth for a few days, while the amount of cream must bear its usual 
ratio to the milk. 

When the child is thin and pale, and the stomach evidently weak 
and d3'speptic, it is well to resort to small quantities of stimulants, and 
to tonics in proper doses. The best stimulant is fine old brandy, of 
which from ten to twentj^ drops may be given three or four times a 
day, or every two or three hours. Or we may administer the aromatic 
spirit of hartshorn in connection with, or without the brandy; of this 



TREATMENT. 569 

about ten or fifteen drops should be given four or five times a day, or 
alternately with the brandy. Of tonics, the most suitable, it seems to 
us, are quinine, in the dose of a quarter of a grain three or four times 
a day. or the citrate of iron and quinine, in the dose of half a grain, 
given in the same way. Another vevy excellent stimulant and tonic is 
the Huxbam's tincture of bark, of Avhich about five to fifteen drops 
may be prescribed in the place of brandy. This kind of treatment 
will scarcely fail to stimulate the digestive power of the stomach to 
greater activity after a few days, and of course to improve the nutritive 
functions and the strength of the patient. In addition to this we would 
recommend the persistent use of the remedies which, as cod-liver oil 
and the compound syrup of the phosphates, are most beneficial in the 
treatment of rickets. The reader is referred to the article on the latter 
subject for more detailed discussion of this point. 

"When the disease is associated with marked intestinal irritation, we 
must inquire carefully into its nature and causes. It maybe connected 
with constipation, diarrhoea, or with an unhealthy state of the contents 
of the bowels. It is often dependent on the presence of crude or imper- 
fectly digested food in the alimentary canal, and when this is the case, 
the only proper method of treatment is to attend to the state of the 
digestive function, and to discover and employ a proper diet. The 
bowels are quite frequently very torpid, and the stools, when obtained 
by medicine, are often found to be very offensive, light-colored, and pasty, 
conditions generally resulting from imperfect action of the liver. Under 
these circumstances small doses of mercurials, or taraxacum, should be 
resorted to in combination with or followed by mild aperients, as 
castor oil or rhubarb. One of the very best cathartic remedies, when 
this combination of symptoms is present, in Chaussier's mixture of 
castor oil and aromatic syrup of rhubarb, consisting of three parts of the 
former rubbed up with five parts of the latter. The dose is a tea- 
spoonful every two or three hours, until the bowels are well evacuated. 
It is gentle in its action, and yet very efficient, gives no pain, and is 
easily taken. If a mercurial be desired, about two or three grains of 
blue mass, one or two grains of calomel, or four grains of the mercury 
with chalk, may be incorporated into an ounce of the mixture. When 
diarrhoea is present, it must be treated according to its causes, as 
recommended in the articles on simple diarrhoea and entero-colitis. 
When, on the contrary, constipation is a marked symptom, this is to be 
treated by regulation of the diet, by the daily use of warm water en- 
emata (particularly recommended by Dr. M. Hall), or, if these do not 
answer, by the exhibition of small doses of the mildest aperients. 

Dr. Hall states that by strict attention to the dentition process, and 
to gastric and intestinal irritation in the dawn of the disease, he has 
succeeded in curing all the cases he has seen but one, and in that he 
found induration of the medulla oblongata. 

By those who suppose the disease to depend on enlargement of the 
thymic, cervical, or bronchial glands, it has been proposed to endeavor 
to procure a reduction of the hypertrophy of those glands by frequent 



570 LARYNGISMUS STRIDULUS. 

applications of leeches, by the use of exutories upon the thorax, by the 
emploj'ment of strong purgative medicines, and by the administration 
of mercury, digitalis, and iodine. In a ease apparently connected with 
enlargement of the bronchial or cervical glands, we should prefer to 
direct our treatment to the invigoration of tlie general health by atten- 
tion to diet, by the use of tonics, and by proper exposure to fresh air, 
whilst ^ve should employ internally, cod-liver oil, iron, iodide of potas- 
sium, the preparations of iodine, and antispasmodics. 

When the disease depends on a centric cause, this must be treated, if 
it can be detected, according to its nature. 

Antispasmodics. — Whatever be the causes of laryngismus stridulus, it 
is undoubtedlj' proper, whilst our chief efforts are directed towards 
their removal or mitigation, to make use of antispasmodics in order to 
moderate the spasmodic symptoms which are but the expression of 
those causes. The remedies of this class most highly recommended 
are cherry-laurel water, belladonna, valerian, musk, assafoetida, oxide 
of zinc, bromides of potassium and sodium, and small doses of ipecacu- 
anha. The most efficient are probably the oxide of zinc, which is rec- 
ommended by M. Brachet (Traite Pratique des Convulsions dans VEn- 
fance) as one of the best antispasmodics that can be used in the con- 
vulsions of children, the fluid extract of valerian, the preparations of 
belladonna, aromatic spirit of hartshorn, and the bromides. M. Brachet 
always combines the oxide of zinc with extract of hyosc^^amus, and 
gives at least two grains of the former with four of the latter, in divided 
doses, in the twentj^-four hours. He states that he has never given 
more than ten grains of each in the period mentioned. Of the flaid 
extract of valerian, about a teaspoonful, or even more, might be given 
in the twenty-four hours, to a child one or two years old. It should 
be mixed with water, of course. The aromatic spirit of hartshorn 
may be given as recommended above. We w^ould also recommend the 
use of the bromides of potassium and sodium in full doses. 

It must never be forgotten, however, that remedies of this class are 
to be employed onl}^ as palliatives and adjuvants, and not as curative 
agents. 

Iron. — Of all the remedies to be employed, after attending in the 
strictest manner to the removal of the exciting causes of the disease, 
there is none of such almost universal applicability as iron or its j^rep- 
arations. The patient is almost invariably, owing to the faulty state 
of the digestive and nutritive functions, more or less ansemical, a con- 
dition imperatively demanding iron ; and as this remedy rarely con- 
flicts with the other means indicated, it should be given probably in 
all, or nearly all the cases. The metallic iron in powder or in lozenges, 
in doses of half a grain or a grain three times a day, or the iodide of 
iron in doses of from two to four drops three times a day, in a mixture 
of syrup and cinnamon-water, are the best preparations, and they 
should be continued, as a general rule, throughout the treatment of 
the case. 

We have already referred to the great value of the prolonged use of 



CASE. 



571 



remedies which improve the general nutrition, and particularly coun- 
teract the rachitic diathesis so often present in cases of laryngismus. 
Among these may be nrientioned cod-liver oil, arsenic, and the alka- 
line phosphates. 

Treatment during the Paroxysm. — When the child is attacked with a 
paroxysm 6f difficult breathing, it should be lifted at once into a sitting 
posture, if it be reclining, and fanned, or carried to an open window, if 
the weather be not too cold. At the same time cold water should be 
sprinkled upon the face, and if the attack be violent, we may resort to 
what is recommended by Dr. Hugh Ley and Dr. Hall, tickling of the 
fauces to produce nausea or vomiting, or irritation of the nostrils with 
a feather, so as to occasion gasping respiration. In a case which oc- 
curred to the late Dr. C. D. Meigs, accompanied with severe general 
convulsions, he found that the suspension of the respiration could very 
generally be broken in upon, and the paroxysm sometimes averted, by 
the application of a piece of ice, wrapped in a cloth, to the epigastrium 
and lower part of the sternum. 

Dr. Edmunds {Med. Times and Gaz., March 12, 1864) also found that 
the application of one of Chapman's ice-bags to the spine, did more than 
anything else to keep off the paroxysms in an obstinate case of laryn- 
gismus. 

To prevent congestion of the brain and effusion, which sometimes 
takes place as the effects of the attacks, Dr. Hall recommended a few 
leeches or cups to the head, the application of an alcoholic lotion over 
the whole head, or the use of the ice-cap. At the same time the bowels 
ought to be speedily moved by large enemata either of simple water or 
of water containing salt. 

In cases, especially of the more general form of internal convulsions, 
where the attacks are so frequently repeated and severe as to threaten 
life, we would recommend the induction of partial anaesthesia by either 
ether or chloroform, as advised in the article on eclampsia. 

Removal to the Country. — When the disease persists in spite of the 
means above recommended, and especially when it depends on dentition 
or digestive irritation^ change of air will often produce a wonderful 
effect, and should always be tried. 

The following cases are reported in full, as illustrating the peculiari- 
ties and treatment of this curious affection : 

Case. — " The subject of this case was a boy, born in July. He was a large, hearty 
child, and remained well until January of the following year, when his mother's 
milk failed, and he was placed upon artificial diet. From this time to May fol- 
lowing, his diet was cream and water, barley-water, oatmeal, arrowroot, pounded 
crackers boiled with water, and giim-water, all of which were tried in turn, being 
prepared and administered with the greatest caution as to time and quantity. A wet- 
nurse was tried, but the child refused the breast entirely. 

" On the 27th January, he was attacked with diarrhcea, which lasted one week. 
This was followed by constipation, the stools being white, firm, tenacious, and oflensive. 
The constipation continued up to July, when it was replaced by diarrhoea. 

"February 4th. On this day, the child being seven months old, was first ob- 
served a spasm of the larynx, producing a shrill, croupal whistle, or ooh^ ooh, during 



572 LARYNGISMUS STRIDULUS. 

two or three successive respirations, and followed by a cessation of breathing for some 
seconds, long enough to dash water in his face, carry him to the window, pat him on 
the back, &c. These spells occurred during the sleeping and waking state, and 
especially during crying or laughing, and continued almost daily and often many 
times a day and night until June, when he was taken into the country. 

"Simultaneously with the laryngeal spasm, appeared contractions of the upper 
extremities, the thumbs being drawn tightly into the palms of the hands, the fingers 
flexed over the thumbs, and the hands bent on the forearms. The backs of the hands 
were swollen, and the skin looked tight and polished. 

" For a few days in the middle of February, there was a subsidence of all the 
symptoms, with decided improvement in every respect. 

" On the 25th of the same month occurred a return of all the symptoms, with ex- 
tension of the spasm to the feet, the toes being bent under the feet, the insteps much 
swelled and having a polished appearance. At the same time there were occasional 
spasmodic movements of the muscles of the face, arms, and bodj^, resembling those 
of chorea. This condition continued with occasional relaxations up to the 11th of 
June. 

" The stomach was exceedingly delicate, rejecting the most carefully selected nour- 
ishment, and at times refusing all food. The child became pale, thin, and timid ; 
was disturbed by the slightest noise, and shunned the light as painful. 

" He was removed to the country on the 11th of June. There his health was grad- 
ually restored. The appetite improved, the spasm of the lar3^nx and contractions of 
the extremities gradually relaxed, and the thumbs were at last liberated, the skin 
under them having taken on the appearance of mucous membrane. There was no 
return of the disease after the middle of June, although the child had a severe 
attack of diarrhoea in Juh^, after which he got perfectly well, and has remained so 
up to the present time (twelve months subsequently). The first tooth made its ap- 
pearance in September, and he now has fourteen, and has cut them all without the 
least accident. During the last eight months he has been remarkably fat and hearty. 

" I am not aware that any medicine had any effect in removing the disease. Cal- 
omel, in large and small doses, antispasmodics of all kinds, frictions over the spine, 
blisters to the back of the head, alteratives, laxatives, &c., were persevered in with- 
out benefit. On removing him to the country, and feeding him on milk warm from 
the cow, at first diluted, and afterwards pure, an improvement was speedily observed." 

The above case, wliich was communicated to us by Dr. Benedict, 
was probably associated with rachitis : unfortunately no record is made 
of the condition of the occiput. The result illustrates most strikingly 
the good effects of removal from the city to the country, and the adop- 
tion of a more healthy diet. 

Case. — The following case is one that occurred to one of ourselves. We extract 
the account of it from a paper on croup by Dr. J. F. Meigs {A^n. Joiirn. Med. Sci., 
April, 1847). 

The patient was a girl, five months of age. We saw the child on the 28th of 
March, 1844. The first attack occurred the day before we were called, but as the 
mother supposed it to be a matter of little consequence, she did not send for me until 
the next day. The child was well grown, and except a rather too great paleness, 
looked strong and healthy. It was playful and good-humored, nursed freely, had no 
fever, and between the paroxysms presented the appearances of perfect health. The 
crowing fits occurred frequently in the course of the day and night, sometimes two 
or three times in an hour, or not so often. They often waked the little thing sud- 
denly from tranquil sleep. They consisted of a succession of long and difficult inspi- 
rations, accompanied by a peculiar whistling or crowing sound, such as might be sup- 
posed to depend on the passage of air through a narrow aperture. During the attack 



CASE. 573 

the face assumed an expression of great anxiety, the respiratory muscles contracted 
with violence, and there seemed to be for the time imminent danger of suffocation. 
After several seconds or a minute the shrillness of the sound diminished, the strag- 
gling subsided, and soon the respiration became perfectly natural, and the child 
seemed well. The paroxysms were usually followed by fits of crying, which, how- 
ever, were easil}- pacified. 

The paroxysms gradually diminished in frequency and violence, and ceased en- 
tirely after the 13th of April. The treatment consisted simply in careful attention 
to the general health, and in the frequent use of warm baths and mild nauseants. 

The child remained perfectly well, with the exception of a slight attack of cholera 
infantum, until the following November, seven months after, when the disorder re- 
curred. Several paroxysms occurred between the 12th and 17th of the month ; but 
as they were slight and unattended by other symptoms of illness, the mother was not 
alarmed, and paid but little attention to them. On the 17th of the same month, the 
child was sitting on the floor amusing itself with some playthings. There were no 
persons in the room except young children. They saw the little thing stoop forward 
suddenly, as though in play, and did not therefore regard it immediately. As it re- 
mained in that position, however, they went to it, took it up, and found it dead. It 
had perished suddenly, no doubt in one of the paroxysms of laryngismus. 

An autopsy was made, in which the larj^nx and thoracic organs were examined, 

but nothing was found to explain the cause of the disease or the sudden death. 

>. 

In the following interesting case, communicated to us by the late 
Prof. William Pepper, the attack consisted of persistent laryngismus 
stridulus, accompanied by frequently recurring internal convulsions 
affecting the diaphragm and other respiratory muscles, and by tonic 

I contraction of the muscles of the arms. 
Case. — A boy, aged four months, remarkably healthy and well-developed, after 
suffering a few days with slight catarrhal symptoms, was suddenly seized with a pe- 
culiar stridulous crowing respiration. 
I saw the child about half an hour from the commencement of the attack, and 
jfound it with a pulse of 140, pale face, and livid lips. The pupils were contracted, 
and the hands firmly clenched ; the crowing sound was very loud, and attended every 
act of inspiration. At times the respiration and circulation would be entirely sus- 

rpended for many seconds, followed by great lividity of the surface and coldness of 
• the extremities. 
Eight or ten leeches were applied behind the ears, the feet placed in warm water, 
and a dose of castor oil administered, to be followed by saline enemata, 

Pour hours from the commencement of the attack, all the sjmiptoms were greatly 
aggravated ; ilie wrists and fingers were firmly flexed, these spasms coinciding with 
the arrest of the circulation and respiration ; there was now perfect insensibility. 
The child was placed in a warm bath, cold water was applied to the head, and a sina- 
pism along the spine, without, however, affording any relief to the crowing inspira- 
tion, or other spasmodic symptoms. 

At the suggestion of Dr. C. D. Meigs, the child was now placed on its right side, 
with the shoulders elevated ; this position to be maintained at least six hours. At 
the end of that time the child was in no respect improved, and accordingly, at the 
suggestion of Dr. M., six leeches were applied over the cardiac region; f^j of lac. 
assafcBtid. was thrown into the rectum, and a blister applied to the back of the neck. 

The child expired at midnight, about ten hours from the commencement of the 
attack, the crowing respiration, with more or less asphyxia, having persisted through- 
out. 

Autopsy, thirty-six hours after Death. — Mucous membrane of the larynx injected, 
but in other respects natural. Thymus gland three and a half inches long, two and 



574 CONTRACTION WITH RIGIDITY. 

a half wide, and at its upper part three-quarters of an inch thick ; its weight was 620 
grains, or 10 drachms and 1 scruple. Lower lobes of both lungs greatly congested. 
Heart natural. The brain, unfortunately, could not be examined. 

It will be observed that, in the above case, the laryngismus and 
other spasmodic symptoms appeared after slight catarrhal symptoms 
had existed for a few days; and it may be possible that the irritation 
of the mucous membrane acted as the exciting cause of the convulsive 
attack. A recent author^ has, however, alluded to the case in such a 
connection and manner, as to at least suggest that he may have mis- 
taken it for one of spasmodic laryngitis. A careful consideration of 
the symptoms and course of the case will, however, sufficiently show 
its essential difference from this latter affection. 



ARTICLE yill. 



CONTRACTION WITH RIGIDITY. 



This is the disease called by the French contracture. We shall treat 
of it as idiopathic contraction with rigidity. It has been little known 
until within a few years, and yet is clearly not a very rare affection 
in Paris, from the number of cases on record in different medical jour- 
nals and works. We have met with but one well-marked example of 
it ourselves in this country. This case, of which we shall give a sketch 
at the end of this article, and the one of larj^ngismus stridulus com- 
municated to us by Dr. Benedict, and appended to the article on that 
disease, furnish very good examples of contraction coexisting with the 
former affection. We have seen also two other cases in which the con- 
traction was decided, but in which it lasted but a short time. 

The disease is evidently one of the forms of eclampsia, which assumes 
such a variety of shapes during infancy and childhood. Though it 
generally exists as an idiopathic and distinct malady, it is in other 
cases associated with, or follows laryngismus stridulus or spasm of the 
glottis, and in others again is combined with attacks of general con- 
vulsions. 

Definition. — B}^ idiopathic contraction with rigidity {contracture of 
the French writers), is meant the involuntary tonic contraction of dif- 
ferent flexor muscles of the extremities, particularly those of the fingers 
and toes, but sometimes of the forearms and arms also, existing inde- 
pendently of any appreciable organic disease of the cerebro-spinal 
axis. It has been described by different English writers in connection 

1 Dr. J. Lewis Smith {op. cit., p. 199). 



SYMPTOMS — COURSE — DURATION. 575 

with laryngismus stridulus, under the title of "carpopedal spasms,'' 
••cerebral spasmodic croup," "croup-like convulsions," &c., &c. We 
believe, however, that it will he useful to describe it separately from 
that disorder, for though of the same nature, and sometimes associated 
with it, it often exists as an independent affection. 

Causes. — It is most common between the ages of one and three 
years. It is much oftener sympathetic than essential, and its most 
frequent causes are dentition, disordered states of the digestive func- 
tion dependent upon improper alimentation, anaemia and its accom- 
panying nervous excitability, brought about by digestive and nutri- 
tive derangements, pijeumonia, bronchitis, masturbation, and unfavor- 
able hygienic conditions. In some few cases, the disease is truly 
essential, since no pathological cause for it whatever can be detected. 
It is merely necessary to say that it is also often symptomatic of disease 
of the brain, but of that form of the affection nothing will be said in 
the present article. 

Mature of the Disease. — It appears to consist in a functional de- 
rangement of the motor tract of the cerebro-spinal axis, occurring 
without any cause that can be detected, or determined by the exist- 
ence of some irritation affecting incident excitor nerves. We once saw 
a child two years of age, who, after a restless, uneasy night, presented 
in the morning tonic contraction of the flexors of all the toes of both 
feet, so that the insteps were swelled, and looked smooth and polished. 
There was no other sign of sickness except peevishness. Learning on 
inquiry that the bowels had been somewhat constipated for several 
days, and that the materials of the scanty stools which had been dis- 
charged were dark-colored and very offensive, we ordered a dose of 
castor oil containing two grains of calomel. The contraction con- 
tinued unyielding until six o'clock in the afternoon, when a very copi- 
ous, dark-colored, viscid, and offensive stool occurred, and the contrac- 
tion immediately ceased. Here the cause of the contraction was evi- 
dently an accumulation of unhealthy fecal matter in the intestine, 
which, by irritating certain sensitive fibres of the excito-motory system, 
caused a reflex motor action that gave rise to permanent muscular 
contractions. In other cases the disturbance of the excito-motory 
system depends on the irritation of excitor nerves occasioned by 
the process of dentition, by indigestion, by diarrhoea, pneumonia, 
pleurisy, &c. In other instances, again, to which the term essential 
must be applied, it seems to depend simply on general debility and 
anaemia, which are w^ell known to be productive of functional disease 
of the nervous system. 

Symptoms; Course; Duration. — The disease rarely attacks children 
previously in good health, but generally those already suffering from 
some disorder of the general health, or a severe local affection. When 
sympathetic, the first symptom noted is the contraction which consti- 
tutes the disease. When essential, on the contrary, the onset is some- 
times marked by various nervous symptoms, such as giddiness, head- 



576 CONTRACTION WITH RIGIDITY. 

ache, or somnolence, which soon pass off, leaving the simple contraction 
with rigidity as the only morbid condition. In most cases, however, 
the attack begins with the muscular contraction, which generally affects 
the superior extremities first, and gradually extends to the inferior. 

When the disease is fully developed, the thumbs are drawn down 
into the palms of the hands, and the fingers, strongly flexed at the me- 
tacarpo-phalangeal articulations, cover and conceal the thumbs. At 
the same time that the metacarpo-pbalangeal articulations are flexed, 
the phalanges themselves remain extended and the fingers are separated 
from each other. The contraction generally affects the wrist-joints 
also, so that the hands are strong!}' flexed upon the forearms, and in 
some rare cases the latter upon the arms. The disorder usually aff'ects 
the inferior extremities likewise, the toes being in a state of tonic 
flexion or extension, the foot rigidly extended upon the leg, and its 
point sometimes drawn inwards. The spasm very rarely extends to the 
knees. 

Children old enough to describe their sensations generally complain 
of stiffness in the affected parts, Avith more or less severe pains darting 
along the course of the nerves. The contracted muscles are hard and 
rigid to the touch, and sometimes enlarged so as to appear in strong 
relief under the skin. In slight cases the contractions can be overcome 
by very moderate force and without pain, whilst in those which are 
more severe, the attempt to overcome the contraction is productive of 
acute pain in the rigid parts. The backs of the hands and the insteps 
jDresent a swollen appearance, and the skin over these points is smooth 
and polished. In the case communicated by Dr. Benedict, appended to 
the article on laryngismus stridulus, and likewise in our own case, the 
skin under the thumbs had assumed the appearance of mucous mem- 
brane, from the long and close confinement of the member. 

In addition to the symptoms already enumerated as characteristic of 
the malady, there are others which require attention. The child is of 
course unable to walk or perform any prehensile movement. The in- 
telligence and senses always remain perfect in simple, uncomplicated 
cases. The nervous system shows signs of disorder in the form of rest- 
lessness or languor, and irritability, with crying and peevishness. In 
the great majority of instances, these are the only nervous symptoms, 
though in some there are general or partial convulsions, strabismus, and 
diminution of sensibility. Of these the most frequent is convulsions, 
which generally come on a few days after the attack, or precede the 
fatal termination. In the case of Dr. Benedict, referred to above, there 
were occasional choreic movements of the face, arms, and body. The 
simple disease is unaccompanied by any febrile movement, and the 
organic functions go on naturally. In the sympathetic form, on the 
contrary, we have the various symptoms of the disease which acts as the 
cause of the contraction, whether that be abdominal or thoracic. The 
most common train of symptoms, in young children, is the same as that 
which accompanies gastric or intestinal derangement, morbid dentition, 
&c. The course and duration of the disease are very irregular and un- 



DIAGNOSIS — PROGNOSIS — TREATMENT. 577 

certain. When once developed it may last from weeks to months, either 
slowly increasing in severity, or remaining stationary for a length of 
time. As a ireneral role, after it has lasted for some time, it becomes 
intermittent, sometimes diminishing or even disappearing entirely for 
a period, then reappearing or increasing, to subside or cease again, and 
so changing without regularity- or evident cause, until at last recovery 
gradually takes place, or death occurs from the concomitant disease, or 
in a paroxysm of convulsions. 

Diagnosis. — The only difficulty in the diagnosis of idiopathic contrac- 
tion is to distinguish it from symptomatic contraction, or that which 
depends upon cerebral or spinal disease. The kinds of cerebral disease 
which most frequently occasion contraction are tubercle of the brain, 
and meningeal hemorrhage. The distinction can generally be made 
with considerable facility, however, by attention to the various dis- 
orders of intelligence and sensibility, to the fever, constipation, vomit- 
ing, and diiferent modes of invasion and progress which characterize 
the symptomatic form. The following table, taken from MM. Eilliet 
and Barthez, will assist in the diagnosis. 

SYMPTOMATIC CONTRACTION. ESSENTIAL CONTRACTION. 

Cerebral symptoms, special functional Similar cerebral symptoms, but only in 

disorders (convulsions, strabismus, dilata- exceptional cases, sometimes accompany- 

tion of the pupils, &c.), preceding or ac- ing, but never scarcely.preceding thecon- 

companying the contraction. traction. 

In many cases irregularity of the pulse. No irregularity of the pulse. 

Generally partial, and commencing Binary, commencing in the fingers and 

usually in the elbows and knees, and in a toes, 
single extremity. 

Almost always permanent. Eemarkably intermittent. 

Prognosis. — The prognosis must depend on the cause of the malady. 
The contraction itself has no influence whatever on the termination. 
The fatal termination has always resulted from the anterior or concom- 
itant disease. Six cases observed by M. Barrier all recovered. The case 
communicated to us by Dr. Benedict, which was connected with laryn- 
gismus stridulus, and one very severe one that occurred in, our own 
practice, also terminated favorably. The prognosis is favorable, there- 
fore, when the attack occurs in a child of naturally good constitution, 
and when the cause of the disease is not a permanent or incurable one. 
The possibility of the occurrence of fatal convulsions should always lead 
us to make a guarded prognosis. 

Treatment. — The treatment must depend on the circumstances under 
which the disease has made its appearance. When it occurs in the 
course of an acute local affection, the treatment must of course be that 
which is proper for the concomitant disorder. When it depends on, 
dentition, or on gastric or intestinal derangement induced by improper 
diet, the treatment is the same precisely as that recommended for 
laryngismus stridulus dependent on the same causes. 

It may be stated that, as a general rule, all violent remedies, as bleed- 
ing, calomel, except in very minute doses as an alterative, drastic 

37 



578 CONTRACTION WITH RIGIDITY. 

cathartics, and blisters, can scarcely fail to be injurious, unless mani- 
festly necessary in the treatment of the concomitant affection. 

It is proper in almost all cases to combine with the treatment already 
recommended, the employment of antispasmodic remedies, particularly 
when the contractions persist after the removal of the primary disease. 

The best remedies of this class are the warm bath, used every day; 
belladonna; conium; bromide of potassium; the fluid extract of valerian; 
assafoetida, and camphor. We would farther recommend the use of rem- 
edies calculated to improve and invigorate the nutrition, and particu- 
larly cod-liver oil and iron. The diet ought generally to be nutritious 
and strengthening, particularly when the patient is weak and delicate. 

In conclusion we may state that the treatment should be very much 
the same as that proposed for laryngismus stridulus, and we therefore 
refer the reader to that subject for more detailed information. 

CASE BY DR. J, F. MEIGS. 

Case. — The subject of this case was a girl nine months old. The parents were 
healthy persons, but the mother, owing to some idiosyncrasy, had made but a poor 
nurse for the preceding child, and I had strongly advised her, therefore, at the birth 
of this one, to give it a wet-nurse. This was not done, however, and it was found 
necessary to feed the infant a great deal fromnts birth. During the early months of 
its life it had some slight attacks of disorder of the digestive system, but being taken 
to the country for several months in the summer, it there improved very much. On 
being brought back to town 1 saw it, and found it pretty well developed, but very 
pale, and, on the whole, delicate-looking. It was still nursed by the mother, but not 
to any very considerable extent, as it was obliged to be fed several times each day. 
The food consisted of different farinaceous substances made with cow's milk. 

On the left forearm of the child there was situated a congenital aneurism by anas- 
tomosis, which had grown, by the age of nine months, to be as large as a five-cent 
piece. It was deemed necessary to remove this tumor, and, accordingly, on the 11th 
of January, 1852, a surgeon tied it with. a needle and double ligature. The child bore 
the operation very well, was soon quieted, and was cheerful and ate well until the 
evening of the 15th, when it was attacked with fever, which lasted all night, and 
was accompanied with a good deal of cough and some gurgling in the fauces. On 
the following morning, at about 7J o'clock, it had a slight convulsive seizure, lasting 
a few moments, and marked by stiffening of the body, and a staring expression of the 
eyes. In the middle of the day, it was seized again, and during that and the next 
day (17th), up to 10 p.m., it had twenty-four convulsions. These lasted from three 
to eight minutes each ; they were general, and consisted of flexions of the limbs, 
working of the face, and were attended with unconsciousness. There was no opis- 
thotonos during the attacks, no extensions of the limbs, and no contraction of the 
jaw. Between the seizures, the child nursed perfectly well, sucked the finger, had 
no stiffness of the lower jaw, and was perfectly conscious. There was, during these 
two days, some fever, as the skin was too warm, and the pulse between 161 and 180. 
The respiration was more frequent than natural, there was a good deal of cough, 
some catarrhal rales in the chest, and also some gurgling in the fauces. The stools 
were scanty, pasty, and white. There was a well-marked but rather faint rash on 
the limbs and trunk, like erythema or mild scarlet fever, and the lymphatic glands 
on both sides of the lower jaw were somewhat swelled, and quite hard. The treat- 
ment directed was one-sixth of a grain of calomel every two hours ; two drops of solu- 
tion of morphia with five of fluid extract of valerian, to be given also every two hours; 
warm immersion baths, and mustard foot-baths. On the second day, blisters were 
applied behind the ears. 

On the 19th, the child was better. There was no convulsion; she noticed well, 
smiled a little, nursed heartily, and took sume arrowroot-water. 



CASE OF CONTRACTION. 579 

Daring all this time the tumor in the arm was not at all inflamed. It was neither 
red, sore to the touch, nor swelled. It was suppurating slightly. Under the idea 
that the convulsions might depend in part on the operation, and in order to promote 
suppuration, a warm poultice was kept constantly applied over the tumor. 

The child continued better, with the exception of slight angina and severe cough, 
until the morning of the 22d, when it waked early, crying violently as though in 
severe pain, and I found the fingers of both hands strongly flexed at the metacarpal 
articulations over the thumbs, which were themselves drawn into the palms of the 
hands. The phalanges, though bent, as just stated, at the metacarpal articulations, 
were stiffly extended at the phalangeal articulations, and at the same time separated 
from each other. The hands were flexed at the wrists. The toes were flexed, and 
the feet stiffly cramped at the ankles, and the insteps, as also the backs of the hands, 
looked swelled and cushiony. Any attempt to open the hands was painful and caused 
crying. The pulse w^as frequent and small, the skin pale, and very slightly too 
warm ; the intelligence was perfect. The jaw was open, and the act of sucking was 
performed, but with some difficulty. On the previous day the bowels had been opened 
three times, and on this day once; the stools were scanty, pasty, and white. At 9 
A.M. I ordered two drops of solution of morphia, five of the fluid extract of valerian, 
and twenty of milk of assafoetida, to be given everj'- two hours. 

4 P.M. — Same state, except that the contraction is stronger. There is more heat of 
skin, much crying, and a restless, distressed motion of the head. At 4|- o'clock, two 
drops of laudanum were given with assafoetida. A teaspoonful of the following mix- 
ture was ordered every hour : 

R. — Mass. Hydrarg., gr. iij. 

01. Eicini, f^iij. 

Syr. Khei. Aromat., f^v. — M. 

10 p. M. — Has taken three doses of the mixture and had one large, whitish, pasty 
stool. Much easier. Has slept a good deal. Contractions not so strong, as the 
hands can be opened more easily, and with very little pain. Skin soft, of natural 
temperature, and moist. Ordered one or two more doses of the mixture, and a repe- 
tition of the laudanum and assafoetida, in case of restlessness. During all this time 
the tumor has not separated. A process of ulceration is going on around the liga- 
tures, but there is nu inflammation of any consequence; the arm is not swelled, and 
there is neither redness nor soreness to the touch. 

January 30th. — The contracture diminished very much for two days, and then re- 
turned, so that during the 27th, and 28th, and 29th, it was very marked, the forearms 
being flexed on the arms, and the hands strongly flexed on the forearms. The feet 
also were very stiff, and strongly flexed. The head was occasionally but not con- 
stantly retracted upon the trunk. The child evidently suffered very much, as it cried 
constantly and was very restless, except when under the influence of anodynes or 
antispasmodics. The bowels are sluggish, but have been kept open by the oil and 
rhubarb mixture. The dejections were generally whitish and pasty, but occasionally 
there was a healthy yellow stool. On the 28th the following mixture was ordered : 

R.— Ext. Valerian. Fluid, fgj. 

Sp. ^theris Comp., f^^ss. 

Liq. Morph. Sulph., gtt. Ix. 

Syr. Tolutan., f^vj. 

Aqu^, f^ij.— M. 

A teaspoonful to be given every hour or two, when there is much suffering- or rest- 
lessness. 

On the evening of the 29th the ligatures were removed, as they had become en- 
tirely loose, though without cutting off the tumor. The diseased point was not much 
inflamed, nor was it very tender. 



680 CASE OF CONTRACTION. 

The child is still nursed and fed. Since the 29th it has had goat's instead of cow's 
milk. On the evening of the 30th the patient was more tranquil, the expression was 
more placid and open, and the contracture not quite so strong. 

Up to February 7th, there was no decided change in the symptoms. They con- 
tinued quite as severe as before. The dyspeptic symptoms, the torpid state of the 
bowels, the want of appetite, and the white, pasty state of the evacuations were never 
relieved, except momentaril}*, by means of cathartics. On the 7th a wet-nurse was 
procured, but only after the most persevering and urgent solicitation and argument 
on our part, I having long been convinced that the cause of the contracture lay in 
the disordered state of the digestive functions, produced and kept up by artificial 
diet, and perhaps by an unhealthy state of the mother's milk. The parents, how- 
ever, had always thought that the operation had been the cause of the convulsive 
disease, and for a length of time would not consent to a wet-nurse. 

After the child had been suckled by the wet-nurse for two days, the stools, which, 
since the beginning of the sickness, now twenty-three days, and to a greater or less 
extent since birth, had been very unhealthy, became yellow, homogeneous, and natu- 
ral in character ; while the bowels, instead of being obstinately constipated, so as to 
require large doses of cathartic medicine, were moved spontaneously two or three 
times a day. 

On the 10th we noticed strong divergent strabismus, and the child looked very 
badly. The left leg was drawn up, whilst the right was stiffened. The left arm was 
more used than the right, the left hand being carried often to the mouth, while this 
was never done with the right. It was diiBcglt to measure the degree of the intelli- 
gence, but the child occasionally looked at and evidently noticed objects, but during 
most of the time it was dull and inattentive. 

On the 13th there was an evident improvement, the previous night having been 
very good. The face was improved in color and expression, and was not quite so 
thin. The contraction was about the same. 

14th. — Some diminution of the contraction, the forearm being a little extended 
upon the arm, and the wrists, though still very rigid, not quite so much drawn. The 
child looks better ; she nurses a great deal, taking all that the mother, and most also 
of what the wet-nurse, a hearty woman, has. 

February 20th. — Doing very well up to last night, when she became more restless, 
cried a great deal, rolled the head on the pillow, and had slight retractions of the whole 
trunk of the body. Occasionally she ceased to cry, scarcely breathed, and the eyes 
were rolled upwards and fixed for several seconds. She looked pale and pinched 
again, and refused to nurse. Had one whitish, curdy stool. 

21^t. — Better ; more quiet ; nurses well. The boring with the head has ceased, and 
also the retractions of the trunk. One healthy stool. 

22d, — Much better ; nurses well ; one healthy stool. The contraction of the right 
arm is yielding, and that of the forearm on the arm is gone on both sides. The left 
wrist is straight ; the right one is yielding very much, though it is still somewhat 
bent. The fingers of the right hand, though still bent, have relaxed very much ; 
those of the left hand are still very much bent, but are less rigid than before. The in- 
tegument of the palms of both hands has become, in the flexures, whitish, soft, moist, 
mucous-like, and has an oftensive odor. To-day and yesterday the child uses the arms, 
touches, and reaches out for articles ; she is much more intelligent, and looks at and 
observes objects ; she now holds her head up, and likes to be carried about sitting up 
in the arms of the nurse, which before she could not do at all. She is gaining flesh ; 
the cojor of the surface is improving ; the ears have become pink and pretty. 

A fresh assafoetida plaster was applied upon the back yesterday. 

March 1st — Continues to do well. The right hand is to-day almost natural, being 
opened and shut, and used to grasp with, though it still looks a little stiff. Left hand 
much better ; she opens and shuts the forefinger, and grasps and holds toys with it, 
but the other fingers are still much contracted. The movements of the arms are quite 
easy and natural. There is no bending of the hands at the wrists, except, perhaps, 



I 



CASE OF CONTRACTION. 581 

very slightly in the left extremity. The feet are natural, except a slight stiffness. 
She now nurses very well, and is growing fat. She is larger, in fact, than before the 
sickness. The intelligence is improving rapidly, as she notices, smiles occasionally, 
and distinguishes, her attendants think, between persons. The bowels are regular 
without medicine. She has taken no remedy of any kind for three days past. 

March 11th. — Almost entireh' recovered. There is still a slight but only very 
slight flexion of the fingers of the left hand. G-eneral health excellent. 

March 29th. — The patient is now perfectly well, except that she uses the forefinger 
of either hand rather better than all together, so that in grasping and holding an 
object, she is more apt to seize it with the forefinger than with all. Still she can and 
does grasp with all, when the object is large, and no one, unless very observant, 
would notice the peculiarity just described. Embonpoint very good ; complexion 
clear and healthy ; sleeps sound ; bowels in excellent condition. Intelligence perfect ; 
smiles and laughs a great deal, and distinguishes between persons ; takes a great deal 
of notice. She is about equal in intelligence to a child of eight months old. Does 
not attempt to speak. 

April 10th, 1852 — I was sent for to-day. The child had not been well for three 
days, having had three or four thin and greenish stools a day, with whitish specks in 
them. She was fretful and did not sleep well, and had a good deal of loose catarrhal 
cough and some acceleration of the breathing. I found her in the morning, after a 
restless night, quite feverish, hot and dry, with frequent respiration, and with some 
catarrhal wheezing in the chest. She had coughed a good deal, and her mother had 
found her hands showing some signs^of spasm, the forefingers being extended as 
though pointing, and separated from the other fingers, which were flexed, with the 
thumbs also, into the palms of the hands. 

There is some degree of laryngismus, as on waking from sleep the breathing is 
labored, difficult, partially suspended, and accompanied with a slight crowing, or 
rather choking sound, while at the same time the face becomes pale and the mouth 
bluish. Bowels open three times yesterday, the stools being mucous, greenish, and 
containing small lumps of undigested casein. 

Ordered a quarter of a grain of mercury with chalk difi'used in a teaspoonful of 
syrup of jalap to be given every two hours. 

At 1 P.M. there was a slight general spasm, with stiffening of the limbs and retrac- 
tion of the head, lasting, however, only a few moments. This occurred again in the 
afternoon. The dose of the mercury and jalap was reduced one-half in the middle of 
the day, as the quantity first ordered was found to cause sickness and vomiting. 

Evening. — Rather better. ISIo fever ; some moisture of the skin ; spasm of the hands 
very much relaxed. The diminished dose of mercury and jalap was well borne. 

11th. — Eather better. Some fever still, with cough, gurgling in the throat, and 
distinct enlargement and hardening of the lymphatic glands at the angles of the jaw 
on both sides. There is still some contraction of the hands. Bowels open freely 
twice last night, and the stools better, being of a pale yellow color, and more homo- 
geneous. The jalap and mercury to be suspended. 

In the course of the day there were two slight general spasms, with laryngismus. 
The latter occurred several times during the waking state, but was not severe. Or- 
dered three drops of syrup of ipecac, with four of sweet spirit of nitre, to be given 
every two hours 

12th. — Much better. Contraction of hands almost gone ; very slight feverishness ; 
cough less frequent and looser ; respiration easy. No spasm to-day. Stools more 
healthy, yellow, homogeneous, and of natural quantity. 

18th. — Continues better. Contraction slight. Cough diminishing very much. 
14th. — Eather pale, dull, and languid. Has had several attacks of laryngismus, 
one of which was quite severe, being attended with deep blueness about the mouth, 
and some of the face also. Does not nurse so well as formerly. The hands exhibit 
decided flexion of the third, fourth, and fifth fingers at the metacarpo-phalangeal ar- 
ticulations, with stiffened extension of the other phalangeal articulations. Thumbs 



582 TETANUS NASCENTIUM. 

slightly drawn into the palms, and the forefingers rather extended. Bowels natural. 
Ordered fifteen drops of brandy, and a very small pinch of the Quevenne's metallic 
iron in powder, three times a day. 

15th. — Condition about the same. On the 22d of March, the first wet-nurse, under 
whose charge the child had improved so rapidly, was changed, on account of some 
objection to her personal appearance, and another one procured in her place. This 
one was a healthy-looking woman, with milk enough, but she was red-haired, irri- 
table, and excessively high-tempered, and the child has been losing ground ever since 
her arrival. Under the idea that her milk did not suit the child, a third nurse was 
by my advice obtained to-day (15th), a calm, placid, fat, and comfortable-looking 
woman, with an abundant supply of milk of ten months old. 

17th. — The child has improved very much. She is fatter already, has a contented, 
tranquil expression, takes more than she did from the previous nurse, and rejects 
much less of the milk. The stools are now regular, occurring twice daily without 
aid, and of a natural appearance. The sleep of the child is better now than it has 
been at any time since the first wet-nurse was dismissed. The attacks of laryngismus 
are already much less frequent, and less severe. The hands are very nearly in a 
natural condition. The child is less nervous, not starting now as formerly at sounds. 

To continue the brandy and iron. 

From this period the child continued to improve regularly in health. She was re- 
moved to the country during the summer months, and when brought back in the 
autumn, was entirely well, with the exception that she was less forward in walking 
than most children, but not more so than might have been expected in one who had 
been dangerously ill for so long a time. Her intelligence was good in all respects, 

February 5th, 1853. — We have seen this child to-day, and find her in very good 
health, except that she is rather smaller in size than is usual at her present ago. She 
has been weaned now for about six weeks, and eats heartily and digests well most or- 
dinary food, as milk, meat, potatoes, &c. The weaning was borne very well, except 
that the appetite was rather deficient and capricious, for about a week after the de- 
parture of the nurse. She can stand up when placed in the erect position, and can 
walk feebly when well supported, but not alone, nor can she rise up from a sitting 
posture. Her intelligence is, in all respects, perfect, but she does not talk as yet. 
There is no vestige of her former spasmodic symptoms, when she is in good health ; 
but any little turn of sickness reproduces some contraction of one leg, and a slight 
flexion of the hands. 

Some months after this, the child was unfortunately seized with hooping-cough. 
She did well for several weeks, but one day, being seized with a fit of coughing while 
seated upon the floor playing, died instantly, doubtless from asphyxia, caused by 
complete closure of the glottis by spasm. This is the only case of hooping-cough that 
we have ever known to prove suddenly fatal in this way. There is every reason to 
suppose that the fatal suspension of respiration was caused by the unnatural excita- 
bility of the sphincter muscle of the glottis, left by the previous attack of laryngis- 
mus stridulus. 



AETICLE IX. 

TETANUS NASCENTIUM. 



Definition; Synonyms; Period of Occurrence; Frequency.— Tet- 
anus nascentiara is a most fatal aflection, occurring principally during 
the first two weeks after birth, usuall}^ running an acute course, and 
characterized by a more or less general tonic contraction of the volun- 



GENERAL CAUSES. 583 

tarv muscles, with paroxj'smal exacerbations, and iisuall}^ without any 
period of complete relaxation until the close of the malady. 

From this definition it will be seen that the affection does not differ 
in its essential nature from tetanus as it occurs in adults; though there 
are so many peculiarities in its causes and symptoms as to demand a 
special discussion. This disease has also been described under the 
names of trismus nascentium or neonatorum, in accordance with the 
prominence and frequency of contraction of the muscles of the lower 
jaw : but as the spasm is rarely limited to these muscles, but usually 
involves the other muscles of the face and those of the extremities, the 
more comprehensive name of tetanus seems more appropriate. It most 
frequently makes its appearance between the third and tenth days 
after birth, although there are cases on record in which it set in fifteen 
hours after birth (West), and others where it did not manifest itself 
nntil the twelfth or fifteenth day. 

Causes. — The causes which have been assigned for the production 
of tetanus nascentium are verj^ numerous; they may, however, be 
generally divided into the groups of general and local. Among the 
local causes, the various morbid conditions of the umbilicus and 
umbilical vessels hold the most prominent place. These are, however, 
far from being constantly present, and yet the weight of evidence 
is at present in favor of regarding diseases of the umbilicus, and 
• more especially of the umbilical arteries, as occasional causes of tetanus 
nascentium. 

In other cases, the disease has been attributed to some blow or 
accidental injurj^ which the infant had received. It is, however, still 
a vexed question as to how much influence should be ascribed to 
these purely mechanical impressions in the production of this affec- 
tion. One of the most powerful efforts yet made to establish their im- 
portance was by Dr. Marion Sims,^ who published a series of articles to 
prove that "trismus nascentium is a disease of centric origin depend- 
ing on a mechanical pressure exerted on the medulla oblongata, and 
its nerves; and that this pressure is the result, most generally, of an 
inward displacement of the occipital bone." This displacement is 
physiological during the parturient state, but its persistence after 
birth is dependent, according to his theory, chiefly upon the improper 
position in which infants are allowed to lie, resting upon their occiput 

» for days together. 

P Further experience, however, has not confirmed this view, nor justi- 
fied the admission of injury to the cranial bones into the list of com- 
mon causes; and yet there are a few cases on record in which tetanus 
undoubtedly appears to have been developed from this source. 

General Causes. — Yicissitudes of temperature appear to favor the 
development of tetanus, since it is frequent in many countries where a 
high temperature during the day is succeeded by great cold during the 

1 Anier. Jour, of Med. Sci., April, 1846, p. 363; July, 1848, p. 59; and October, 
1848, p. 355. 



584 TETANUS NASCENTIUM. 

night. In the same way, exposure of the infant to wet and cold, as by 
putting damp clothes upon it, may be productive of the disease. The 
most frequent and well-established cause of tetanus nascentium, how- 
ever, is a vitiated state of the atmosphere; whether engendered by a 
filthy condition of the bedding or house, or by imperfect ventilation; 
and it is to this that we must attribute the frequency of the affection 
in such dissimilar localities, as the Western Hebrides, Iceland and the 
neighboring islands, Minorca (see Cleghorn, Observ. on Epidemical Dis- 
eases of Minorca^ London, 1768, p. 81), and some of the Southern States 
of America, where it was formerly not at all unusual for 50 per cent, 
of all infants born to perish during the first two weeks from this cause 
alone. It was formerly supposed that certain localities, pre-eminent 
among which are those just mentioned, were peculiarly favorable to 
the development of this disease, but it is probable that no predisposi- 
tion exists excepting the fluctuations of the climate and the filthy 
habits of the people. 

The very great importance of filth and deficient ventilation as a 
cause of tetanus nascentium is, however, most forcibly shown by the 
great reduction in the frequency of this disease in large Ij^ing-in asy- 
lums, effected by the introduction of more thorough ventilation and a 
greater regard to cleanliness. This was conclusively demonstrated in 
the Dublin Lying-in Asylum towards the close of the last century. 
Previously to the year 1782, of 17,650 infants born alive in the as^ium, 
2944, or almost one-sixth, had died within the first fortnight, and in 
almost ever}' one of these the cause of death was tetanus nascentium. 
During the next seven years, after Dr. Clarke had simply introduced 
a much more complete system of ventilation in the wards, of 8033 
children born, only 419 in all died, or about 1 in 19, or 5Uh per 
cent. 

Our comparative immunity in this part of America, even among the 
poor in our cities, is probably due to the greater degree of cleanliness 
in their houses, and to the improved construction of our hospitals and 
asylums. In New York, however, according to Dr. Smith,^ there are 
more deaths from tetanus during the first year of life than at all other 
ages together. 

The mortality returns of this city indicate that tetanus, although 
comparatively frequent among infants, is much less so than in New 
York. 

Thus during the 9 years, from 1860 to 1868 inclusive, the returns 
show a total mortality (less still-born), at all ages, of 127,563, and 
under 1 year of 36,765. During this period there were 233 deaths 
from tetanus at all ages; 61 of which were during the first year of life, 
and 157 after that age. Thus the proportion of deaths from tetanus to 
those from all causes was, after the age of one year, as 1 to 598, and 
during the first year of life, as 1 to 602. 



1 Amer. Jour, of Med. Sci., July and October, 1865; and op. cit., p. 168. 



PATHOLOGICAL APPEARANCES. 585 

During this same period, the number of births in Philadelphia, 
amounted to 146,895. 

Pathological Appearances. — We have already alluded to the mor- 
bid conditions of the umbilical vessels or umbilicus occasionally found 
in tetanus nascentium; it is evident, however, that if these lesions have 
any connection with the disease, they merely act as exciting causes. 

The only characteristic lesions of this affection are presented by the 
nervous system. 

The brain and its meninges are frequently found intensely congested, 
though this is not so uniformly present as a similar condition of the 
spinal cord; according to numerous observers, however, it is more fre- 
queiitl}' present than absent. In some cases, this congestion has led to 
an actual effusion of blood, either between the skull and dura mater, 
into the arachnoid cavity, or into the ventricles. In some cases, in- 
stead of hemorrhage, there has been found serous effusion into the 
ventricles or into the subarachnoid space, accompanied with a diminu- 
tion of consistence of the cerebral substance, as reported by Matus- 
z^'nski. 

The morbid appearances found in connection with the spinal cord 
are the same in character as the above, but more constant and even 
more marked. The vessels of the spinal meninges and of the substance 
of the cord are intensely congested, and there is frequently effusion of 
blood into the cavity of the arachnoid. 

The value of these appearances was formerly underestimated from a 
suspicion that they might bo partly, at least, due to the mere gravita- 
tion of the blood after death. This suspicion has, however, been en- 
tirely removed by the observations of Weber of Kiel, and Finckh of 
Stuttgardt, who placed the bodies of infants dying with tetanus in va- 
rious positions before examining them, and yet invariably found the 
above-mentioned conditions. 

There is, however, a further source of doubt as to the significance of 
these lesions. We have already seen, in speaking of eclampsia, an af- 
fection in which no appreciable material lesion has as yet been de- 
tected, that, in a certain proportion of cases, congestion, serous effusion, 
or actual hemorrhage might be present not as causes but as effects, and 
due merely to the intense venous engorgement caused by the embar- 
rassment of the respiration and venous circulation during the convul- 
sion. It is, indeed, it seems to us, highly pi'obable that a similar 
interpretation may be placed, in many cases at least, upon the morbid 
appearances above mentioned as being found after death from tetanus 
nascentium. 

We have thus enumerated the lesions of the nervous system which 
are readily discoverable in many fatal cases of tetanus; and yet these 
lesions are, it will be observed, almost without exception concerned 
merely with the vascular supply of the brain and spinal cord, and we 
are as yet without any accurate investigations into the condition of the 
nervous tissue itself Within the past few years, the wonderful ad- 
vances of microscopical science, as applied to pathological anatomy, 



586 TETANUS NASCENTIUM. 

have revealed structural changes in the nervous system in connection 
with more than one disease, whose pathology has heretofore been ut- 
terl}' obscure, and it is not too much to hope that at no distant period 
the question of the presence of any definite structural change in the 
brain or spinal cord in cases of tetanus nascentium will be positively 
settled. In connection with this suggestion, especially in consideration 
of the analogy between this disease and tetanus in the adult, we 
append the results of the investigations of Rokitansky and Demme 
upon the microscopical appearances in the spinal cord in fatal cases of 
this latter affection.^ 

1. The constant anatomical character of tetanus appears to be pro- 
liferation of the connective tissue (of the cord) ; the most striking pe- 
culiarity of this lesion is the extent over which it is found. 

2. The 23roduct is a viscous mass, abounding in nuclei; it remains at 
this stage of development in both acute and chronic cases, never pro- 
gressing to the formation of fibres. 

3. This change is found almost exclusively in the white medullary 
substance; the gray matter seems to suffer only secondarilj-, and then 
from compression rather than interstitial deposit. 

4. The proliferation is not always followed by corresponding swell- 
ing of the white matter ; it can often be recognized only by means of 
the microscope. 

5. It was principally found in the medulla oblongata, the crura cere- 
bri; the inferior peduncles of the cerebellum, and in the greater part of 
the spinal cord. 

6. This lesion of the connective tissue appears to be due to long-con- 
tinued or repeated congestions. 

7. The period at which it occurs, probably varies in different cases. 
These observations, which were originally published about 1860, have 

been confirmed in all essential particulars by Wagner (^Syd. Soc. 'Year- 
Book, 1862, p. 219); and still more lately by J. Lockhart Clarke, who 
published in the Med.-Chir. Trans., vol. xlviii, the results of the micro- 
scopic examination of the spinal cord in six cases of tetanus, in all of 
which structural lesions were discovered ; and by Dr. Dickinson (Med.- 
Cliir. Trans., vol. li, p. 265). 

Symptoms. — There are rarely any premonitory symptoms of the at- 
tack, but the onset and development of the disease are usually gradual. 
The earliest symptom noticed is, in most cases, difficulty in nursing; 
the infant appearing anxious to nurse and eagerly pressing its mouth 
against the nipple, but being unable to fully take it into the mouth or 
to suck, from a rigid condition of the masseter muscles. At the same 
time it utters a whimpering, whining, unnatural gvj. 

The tonic muscular contraction very rarely remains limited to the 
masseters, but soon invades the other muscles of the face, and those of 
the trunk and extremities. 

The expression of the face thus produced is indicative of great suffer- 

1 Schmidt's Jahrb., vol. iii (in New Syd. Soc. Year-Book, 1864, p. 282). 



SYMPTOMS. 587 

ino-; though it is impossible to say how truly this represents the sensa- 
tions of the patient. 

The face is drawn into wrinkles and furrows, and has a strange appear- 
ance of age. The condition of the mouth, however, is most characteris- 
tic ; the jaws are firmly fixed, the lips slightly separated and pressed 
firmly against the gums, and the angles of the mouth drawn backwards 
and downwards, in the well-known risus sardonicus. 

During this time, the other voluntary muscles gradually become rigid. 
At first, their contraction can be overcome by the use of a moderate 
degree of force, but in the course of twelve or twenty-four hours the 
period of maximum rigidity is attained. The head is drawn back- 
wards, and firm!}' fixed; the arms are flexed, and the hands clenched, 
with the thumbs drawn across the palms. The thighs may be flexed 
upon the pelvis, or the legs crossed; the great toes are usually ad- 
ducted and separated from the rest, which are flexed. 

The contraction of the dorsal muscles frequently produces opisthoto- 
nos; and the entire body is at times rendered so rigid that it can be 
raised, without bending, by placing a hand under the heels and head. 
This extreme degree of spasm of all the voluntary muscles may never 
be developed in some cases; or, when present, it often is not persistent. 
When the infant is quiet or sleeping, there is usually a certain degree 
of relaxation. It is a marked peculiarity of the affection, however, 
that exacerbations of the tonic spasm are produced by the slightest 
exciting causes, as an effort at deglutition, a sudden noise, a puff of air, 
the most delicate touch, or even the alighting of a fly upon the surface. 
During these paroxysms or clonic spasms, the muscular rigidity and 
contraction attain their greatest height, and produce the most painful 
distortion of the face and limbs. The fit, according to West, may be 
ushered in by a screech. During its continuance, there is serious inter- 
ruption of respiration and circulation; the surface becomes livid, and 
epistaxis may occur. It is during this condition, too, that hemorrhages 
into the brain or spinal cord, or their meninges, may result. 

These paroxysms recur at irregular intervals, but usually, in fatal 
cases, occur with increasing frequency until either the child expires 
sudder)ly during one of the fits, or passes into a state of coma. 

The pulse does not present any characteristic change; in some cases 
it has been found accelerated, but in others has continued normal, or 
has even fallen below the healthy rate. 

The condition of the bowels is not uniform. Diarrhoea is frequently 
present, but is probably due to irritation of the bowels from the irritat- 
ing nature of the ingesta, or to some accidental cause; particularly as 
the bowels are occasionally constipated in well-marked cases. 

The appetite generally appears to continue, but we have already al- 
luded to the fact that any attempts to feed the child bring on violent 
spasms, which expel the greater part of the food taken into the mouth. 
Owing principally to this obstacle to the nourishment of the infant, 
the emaciation is more rapid and marked in this than in almost any 
other affection of infancy. 



588 TETANUS NASCENTIUM. 

The state of the pupils in tetanus nascentium has not been noted 
with sufficient frequency or accurac}' to allow an}^ deductions to be 
drawn with regard to it. Smith has seen the pupils contracted in the 
last stage of the disease. 

Prognosis. — The majority of authors state that they have never met 
with a case of recovery from fully established tetanus nascentium. 

Dr. Smith has, however, collected 8 cases of recovery, in the histo- 
ries of which he calls attention to two important peculiarities ^ that 
the children were all about a -week old when the initiatory symptoms 
appeared, and that there were fluctuations in the symptoms of the dis- 
ease. The only circumstances, then, which would lead us to form a less 
gloomy prognosis than usual, are the late appearance of the disease, 
and the mildness and intermitting character of the sj^mptoms. 

The diagnosis of this affection presents no difficulties, being readil}^ 
made by attention to the persistent muscular contraction, the inability 
to suck or to take food, and the exacerbations which are produced by 
the slightest causes. 

Duration. — In fatal cases, the duration rarely exceeds fort^'-eight or 
sevent3"-two hours, and death frequently occurs during the first day. 
There are instances, however, in which its course has been prolonged 
to the sixth, or even the ninth day; and Smith refers to two remark- 
able fatal cases, recorded by Underwood and Elsasser, in one of which 
the. duration ^vas six weeks, and in the other thirty-one days. 

Dr. Wells has reported {Brit. Med. Jour., Dec. 21st, 1861) the follow- 
ing case of chronic trismus: The child died at the age of one year — 
having been, from its birth, in a state of tonic spasm or trismus; it was 
always restless, and appeared ill nourished, though there was no reason 
for this. All treatment was unavailing. It was suggested that the 
child's state might proceed from irritation due to the mother's milk; 
and the child was weaned, but without benefit. At the post-mortem 
examination, there was found a considerable opalescent effusion over 
the surface of the brain; the cerebellum was harder than usual, and 
on being cut into presented a homogeneous appearance. The arbor vitse 
was entirely wautirig. 

In favorable cases, the duration varies from a few days to one month, 
or even more. 

In the 8 favorable cases collected by Smith, the duration was, in 1 
case, two daj's; in l,a few days; in 1, fourteen days; in 2, fifteen days; 
in 1, twentj'-eight days; in 1, thirty-one days; and in the remaining 
case, about five weeks. 

Prevention and Treatment. — It is fortunate that we can by wise 
hygienic measures do much to prevent the occurrence of a disease of 
such fatality, and in which, when once fully developed, treatment is so 
unavailing. AVe have already alluded to the vast diminution in the 
number of deaths from this disease, which followed the introduction of 
free ventilation and cleanliness into the wards of the Dublin Lj'ing-in 
Hospital. Nor are the good effects of this practice limited to public 
institutions, but it has been found that wherever the disease has pre- 



PREVENTION AND TREATMENT. 589 

vailed to any extent, as on the Southern plantations, its progress can 
be arrested by insisting upon the observance of cleanliness in bedding 
and clothing, of mother and child; b}^ cleaning, disinfecting, and freely 
ventilating the houses; by care in dressing the umbilical cord; and, 
finally, by attention to the food of the infant, and the condition of its 
bowels. 

Eren when the disease has made its appearance, these same measures 
should be carried out with equal care, since by removing all possible 
causes, so far as we are acquainted with them, we may mitigate the 
severity of the attack. 

In addition to the removal of the causes, the strictest quiet should 
be enjoined, and all care employed to avoid exciting the violent par- 
ox^'sms, which are so readily induced. 

It would be well, in addition, to examine the occipital region, to dis- 
cover if the occipital bone be unnaturally depressed, since in one or two 
cases this has appeared to act as the exciting cause of the attack. If 
such depression be found, the position of the child should be varied by 
placing it on its side, in accordance with the recommendation of Dr. 
Sims. 

The application of leeches to the nape of the neck or along the spine, 
appears indicated in the early stage of the disease. Dr. West advises 
the practice, though he has had no experience in its use. Collins, how- 
ever, states he has tried frequent leeching along the spinal column, 
without the least benefit. 

Purgatives are only useful to the extent of maintaining regular 
action of the bowels. 

The remedies which have been most highly recommended as directly 
curative, are ether and chloroform, and various narcotics and antispas- 
modics, as opium, hydrate of chloral; belladonna, aconite, cannabis In- 
dica, conium, w^oorara, tobacco, and assafcetida. 

Anaesthetics have been employed frequently in tetanus of the adult, 
and occasionally in the affection under discussion. Despite, however, 
the great expectations which were entertained in regard to their 
utility, their action cannot be considered directly curative. They re- 
lieve sufi^ering, however, and by temporarily allaying the spasmodic 
contraction of the muscles, enable us to administer food or remedies, 
and thus prolong life, and give time for other agents to act. " So long, 
therefore, as the patient is able to take food and to obtain periods of 
comparative quiet, the use of angesthetic inhalations is not desirable. 
Great advantages may, however, be obtained from them if he be unable 
to open the jaw sufficiently to permit of taking food, or if the tetanic 
spasms are without remission. Ether appears to have stronger facts in 
its recommendation than chloroform." (J. Hughlings Jackson and Hut- 
chinson's Eeport on Tetanus, Med. Times and Gaz.^ April 6th, 1861.) 

The evidence in regard to the superior efficacy of any particular nar- 
cotic, is highly conflicting. Opium has, until recently, been the one 
usually relied upon, and several recoveries have occurred under its use. 
Of late years, however, various other narcotics have been employed, 



590 TETANUS NASCENTIUM. 

especially in traumatic tetanus in the adult. Thus belladonna and its 
alkaloid atropia have been used, the latter hypodermically, with occa- 
sional good results. If the sulphate of atropia is used hypodermically 
in infants, the first dose should not exceed the ^-^^^^^ ^^' yio^^ ^^ ^ grain, 
so that its effects may be tested carefull}^ One half grain of the salt 
may be dissolved in a fluid ounce of water, and four to six drops injected 
under the skin along the spine. 

The various preparations of cannabis Indica have also been exten- 
sively used. Dr. Gaillard reports two cases of recovery from tetanus 
nascentium under this treatment; in one of which the infant, aged 
eight days, took as much as f^ss. of tincture of cannabis Indica in a 
single day — being equivalent to about eleven grains of the pure ex- 
tract. This quantity, however, appears excessive, 

Woorara has been given in twenty-two cases, according to Demme, 
with eight cures. It has been recommended bj^ Harley, Spencer Wells, 
Broca, Yella, Chassaignac, and others. The dose in which this poison- 
ous substance has been given, is from one-eighth to one-half a grain to an 
adult. The great objection, however, to both this remedy and cannabis 
Indica, is the great want of uniformit}^ in the strength of their prepa- 
rations, which necessitates the utmost caution in their use. 

More recently still, numerous cases of tetanus in the adult have been 
treated with the various preparations of conium, and with its alkaloid 
conia, and also with hydrate of chloral, and the results have been of a 
decidedly encouraging character. 

Among the antispasmodics most frequently used, are assafoetida and 
tobacco^ either given internally or by enema, or added to a warm bath. 
There is no very positive evidence, however, of their efficiency in this 
disease. 

Baths, either of warm water or vapor, should be repeatedly given ; 
they tend to act favorably as sedatives^ by relaxing the muscular spasm, 
and, in addition, excite the action of the skin. 

The free use of large doses of quinine, usually in combination with 
one of the narcotics above mentioned, appears to be serviceable in trau- 
matic tetanus, by reducing the frequency of the pulse and mitigating 
the tendency to spasm, so that the induction of cinchonism in tetanus 
nascentium is a measure worthy of a fair trial. 

The application of ice to the spine has been highly recommended in 
tetanus in adults, and is reported to have been used with success in 
several cases. The condition of the bloodvessels of the cord and its 
membranes, in fatal cases of tetanus nascentium, would certainly appear 
to indicate its use in this affection also. 

Whichever of the above plans of treatment may be adopted, it must 
never be forgotten that one of the principal dangers and most frequent 
causes of death in this disease, is the obstacle offered to the nourish- 
ment of the infant. We must pay attention, therefore, to the adminis- 
tration of milk, meat-broths, and alcoholic stimuli in small quantities, 
but frequently repeated; and if the rigidity of the jaw and the occur- 
rence of spasms upon every attempt at deglutition, prevent the child 



CHOREA. 591 

from taking food, Tve should have recourse to anaesthetics to relax the 
spasmodic muscular contraction, and enable us to get nourishment into 
the stomach. 



AETICLE X. 



CHOREA. 



Definition ; Synonyms ; Frequency. — Chorea is a non-febrile, con- 
vulsive disease, characterized by irregular and imperfectly co-ordinated, 
but not completely involuntary contractions, of different parts of the 
muscular system, and particularly of the muscles of the face and of 
the extremities. 

It is called also St. Yitus's dance, chorea sancti viti, choreomania, 
epilepsia saltatoria, and by various other titles. 

It is evidently impossible at present to determine the frequency of 
chorea, as it rarely proves fatal, and consequently scarcely figures in 
the mortality reports. It must, however, be quite frequent, since it 
rarely happens to us not to have several cases under treatment at any 
one time, either in private practice or in some public institution. M. 
Eufz states {Diet, de Med., t. vii, p. 544), that of 32,976 children admit- 
ted into the Children's Hospital of Paris in ten years^ only 189 were 
affected with chorea, or 1 in 377. 

Predisposing Causes. — Age. — Chorea very rarely occurs during in- 
fancy. According to M. Eufz, it is seldom met with between one and 
six years of age, since of 189 cases, in only ten did it occur within that 
period; while between six and ten years of age it is much more com- 
mon (61 in 189 cases); and between ten and fifteen years still more so 
(118 in 189). 

M. See, in a valuable essay on chorea (^Mem. de VAcad. Nat. de ^lede- 
cine., t. XV, p. 373), and the relations of rheumatism and diseases of the 
heart with nervous and convulsive diseases, states (page 448), that of 
531 cases of chorea treated in the Children's Hospital at Paris, during 
a period of twenty-two years, 28 were under six years, 218 between 
six and ten years, and 235 between six and fifteen years of age, M. 
See concludes, after carefully sifting the facts, that the true maximum 
of frequency is comprised between six and eleven years of age, and that 
it corrcvsponds especially to the tenth year. Under six years of age it 
becomes more and more rare as we approach the moment of birth. MM. 
Simon and Constant, however, met with it in nursing children of twelve, 
six, and four months of age. 

The statistics furnished by Hillier^ confirm these statements in every 
detail. Thus, of 422 cases treated as out-patients at the Children's Hos- 



1 Diseases of Children (Amer. ed., 1868, p. 234). 



592 CHOREA. 

pital in London (where no patients over twelve years are received), the 
numbers at different ages were as follows: 

From 3 months to 6 months, . 3 



6 " 


12 


u 


. 5 


2 " 


18 


(( 


. 2 


8 " 

2 years 

3 " 


2 
3 
4 


years, 


4 

. 6 
. 11 


4 " 


5 


<( 


. 20 


5 " 


6 


il 


. 30 



rom 6 years 


to 7 years, 


48 


" 7 '' 


8 '' 


51 


u 8 u 


9 " 


58 


u 9 u 


10 " 


80 


u 10 u 


12 " 


104 



422 



JSex. — It is much more frequent in girls than boys. Of the 531 cases 
cited by M. See, 393 occurred in girls, and only 138 in boys. This is 
the same result as that attained, M. See remarks^ by Eeeves, Good, &c., 
— 131 girls in 186 cases. This accords entirely with our own experi- 
ence, and in a very interesting statistical report by Dr. George S. Ger- 
hard, based on 30 cases observed in this city {Phila. Med. Times, 1873, 
vol. 2), the number of female patients just doubles that of the males, 
20 to 10. 

This excess of females over males obtains in chorea of every grade, 
from the mildest to the most rapidly fatal cases. 

Rapid growth and the second dentition probably act, in a considerable 
degree, as predisposing causes of the disease. Particular attention is 
drawn to these conditions by MM. Eiiliet and Barthez, and the precise 
age at which it is most frequent (between six and eleven years), would 
seem to show that they exert a very positive influence. The general 
deterioration of the health, resulting in anaemia, and the exaggerated 
nervous susceptibility, so often observed at these periods, are probably 
the immediate causes of the frequency of the disease at this epoch of 
life. 

Drs. Gerhard (loc. cit.) and S. Weir Mitchell report that they have 
observed that chorea occurs more frequently and in a more severe form 
in the spring than at any other season ; and also that relapses of the 
disease are most apt to take place at that time. They think this is 
probably attributable to the condition of weakness of the system, 
which exists in the spring. 

An altered and anaemic state of the 'blood has also been supposed, as 
by Ogle^ and Barnes,^ to be the efficient and exciting cause of the affec- 
tion. Eiiliet and Barthez,^ also, when speaking of rheumatism as a 
cause of chorea, say that, "while admitting the existence of rheumatic 
chorea, it must not be forgotten that the disease is frequently of a dif- 
ferent nature, and that we meet in authors with incontestable examples 
of chorea consecutive to chronic diseases that have produced a debili- 
tated condition of the economy, ... as chlorosis, anaemia, and tuber- 
culosis." 

1 Brit, and For. Med.-Chir. Kev., Jan. and April, 1868, pp. 208, 465. 

2 Chorea in Pregnancy. Proc. of Obstet. Soc. of London, vol. x, 1868, p. 147. 

3 Op. cit., 2eme ed., t. ii, pp. 565-598. 



RHEUMATISM AS A CAUSE. 593 

Constitution does not seem to exert much iDfluence in its production, 
though it is generiil)}^ thought to be most apt to occur in children of 
delicate, excitable, and nervous temperament. The belief in hereditary 
predisposition seems to be unfounded save in rare cases. The disease 
appears to commence more frequently in spring and summer than in 
winter, and yet it is scarcely known in tropical climates. 

Rheumatism, however, is unquestionably the condition in connection 
with which chorea occurs far more frequently than with any other, or 
perhaps than with all others conjoined. The evidence of all observers 
of experience is unanimous upon this point. M. See (loc. cit.) asserts, 
after much examination of this subject, that one-half the cases of chorea 
are dependent upon the rheumatic poison. Thus of 109 cases of rheu- 
matism admitted into the Hopital des Enfants, he found that 61 were 
complicated with chorea. Trousseau^ also states that in his experience 
rheumatism was undoubtedly the most marked cause of chorea. M. 
Henri Eoger^ asserts their connection even more strongly, and states 
that "the coincidence of chorea and rheumatism is so common a fact 
that it ought to be regarded as a pathological law, just as much as the 
coincidence of heart disease and rheumatism." 

In England, also, this connection between rheumatism and chorea, 
both of the mild and severe or fatal form, is positively stated by numer- 
ous authorities. Thus in 104 cases of the list collected by Dr. Hughes,^ 
" where special inquiries were made respecting rheumatic and heart 
affections, there were only 15 in w^hich the patients were both free from 
cardiac murmur, and had not suffered from a previous attack of rheu- 
matism." Hillier (op. cit., p. 236) " believes there is a very close con- 
nection between these diseases." West (op. cit., 4th Am. ed., p. 188) 
says : " Be the exact relation then what it may, it does seem that rheu- 
matism, or the rheumatic diathesis, is a very powerful predisposing 
cause of chorea." Dr. H. M. Tuckwell, in a valuable article* on the 
pathology of chorea, strongly upholds their frequent connection, and 
cites 17 cases of his own, in 11 of which the previous occurrence of 
rheumatism was allowed, while it was denied only in 6. 

Dr. Chambers found that out of 33 cases of chorea in his books, in 6 
the affection either began during rheumatic fever, or followed immedi- 
ately after it, or else rheumatic fever succeeded to the chorea. In 80 
cases of non-fatal chorea recorded by Ogle,^ it appears that in 8 cases 
rheumatic fever had existed. 

On the other hand, several German authors of high authority do not 
attach so much importance to the causative influence of rheumatism in 
chorea. Thus Eomberg^ states that he has not observed their connec- 

1 Clin. Med., 2eme ed., t. ii, pp. 160-198. 

2 Arch. Gen. de Med., 1866, vol. ii, p. 641 ; and 1867, vol. i, p. 54; and Gaz. Med. 
de Paris, March 7, 1868. 

3 Guy's Hospital Rep., 2d series, vol. iv, 1846. 

4 St. Earth. Hosp. Eep., vol. v, 1869, pp. 86-105. 

6 Brit, and For. Med.-Chir. Rev., April, 1868, p. 490. 
6 Dis. of Nerv. Syst. (Syd. Soc), 1853, vol. ii, p. 57. 

38 



694 CHOREA. 

tion frequently; and YogeP states that, ^' although it must be acknowl- 
edged that chorea may succeed to acute rheumatism, still the frequency- 
of the occurrence has been very much overestimated." 

Steiner'^ also states that out of 252 cases of chorea the disease ensued 
during the decline of acute articular rheumatism in but 4 cases ; of 3 
fatal cases, however, reported by him, one was complicated with rheu- 
matic heart disease. 

We must also allude to the argument of Yogel {op. cit., p. 399), that 
if there were any actual connection between these diseases, then more 
girls than boys ought to suffer from rheumatism; for it is well known 
that the former are predominantly subject to chorea. "Just the re- 
verse haj^pens to be the case in rheumatism, which notoriously attacks 
more boys than girls." We have already quoted extensive statistics, 
which prove the truth of the first of Yogel's statements; but we are by 
no means convinced that the latter is correct, and that rheumatism is 
more frequent in boys than in girls. On the contrary, the statistics 
quoted by Tuckwell (loc. cit., p. 102) go to show that the reverse even 
may be the case. Thus during sixteen years there were admitted to 
the Children's Hospital in London 478 patients with rheumatism, 252 
of Avhom were females, and 226 males. 

We are not aware of the existence of any accurate statistics of the 
disease in this country in regard to this point, excepting those of Ger- 
hard (loc. cit.'), in whose 30 cases rheumatism was assigned as the cause 
in only 4. 

The great weight of evidence, however, which has been accuniulated 
in favor of such a connection, together with the decided results of our 
own observation, appears to us to leave no doubt that in a considerable 
proportion of cases, though by no means in all, chorea in some way 
depends upon the existence of rheumatism, or the rheumatic diathesis. 
We shall have occasion to call attention to the obscurity which fre- 
quently attends the manifestations of rheumatism in young children; 
and it is, therefore, highly probable that in not a few cases of chorea, 
where, on inquiry, the parents deny the previous occurrence of rheu- 
matism, the truly rheumatic nature of some acute febrile attack, with 
which the child may have suffered months before, has been entirely 
overlooked. 

We will postpone, until we come to discuss the nature of this affec- 
tion, the consideration of the manner in which rheumatism disposes 
to chorea, whether by directly causing centric lesions, as of the spinal 
meninges; or by inducing a state of anaemia, impaired nutrition, and 
preternatural mobility of the nervous system; or whether the choreic 
movements are in some way connected with cardiac disease, which so 
frequently attends rheumatism in the j^oung. 

Exciting Causes. — Of many exciting causes that have been men- 

1 Op. cit., p. 399. 

2 Prag. Yjrschr. xcix (xxv, 3), p. 43, 1868; in Schmidt's Jahrb., Bd. 142, No. 4, 
1869, p. 26. 



ANATOMICAL LESIONS. 595 

tioned by different writers, the one most frequent and most clearly 
proven, is the influence of terror. It was assigned as a cause in 31 out 
of 56 cases collected by Duffosse and Bird, in 34 out of 100 cases col- 
lected by Hughes, in 25 out of 128 by See, in 9 out of 31 by Peacock, 
in 9 out of 38 by Hillier, and in 7 out of 30 by Gerhard. Besides this 
are cited imitation, blows and falls upon the head, fits of violent anger, 
contrarieties, prolonged excessive mental effort in young subjects, mas- 
turbation, the diflScult establishment of the menstrual function in girls, 
or suppression of that function, the sudden drying up of ulcers or erup- 
tions, and, in females after puberty, pregnancy, which indeed is a well- 
ascertained and most important cause. 

Chorea has also been observed in the coarse of, or as a sequel to, 
various acute diseases, as pneumonia, the eruptive, typhoid, and inter- 
mittent fevers, and affections of the gastro-intestinal tube. 

Anatomical Lesions. — It would appear that as yet we are unac- 
quainted with any truly characteristic lesion in chorea. In many of 
the recorded autopsies, it is stated that no lesion either of the cerebro- 
spinal axis or any other viscus was present. As, however, most of 
these autopsies were made before the improved methods of microscopic 
examination of the nervous system were introduced, they cannot be 
regarded as conclusive upon this point. In many cases, also, the ex- 
amination of other viscera has been too superficial to have led to the 
detection of minute but positive and important lesions. Upon the 
whole, therefore, it may be fairly said, that it is chiefly the examina- 
tions which have been made during the past few years which are of 
real value, and that there is still need of numerous accurate autopsies 
before we can consider ourselves justified in speaking of the true lesions 
in chorea. 

It is evident that the determination of this question presents great 
difficulties, ajoart from the fact that fatal cases of chorea are compara- 
tively rare, and that it requires an amount of skill and patient labor, 
rarely at command, to make the examination with the requisite mi- 
nuteness. One of these difficulties consists in the fact that, although 
chorea may exist as a special, individual affection, there are numerous 
other cases of nervous disease which are of very varied nature, but 
which are attended with irregular muscular movements truly choreic 
in character. 

We think it highly probable, therefore, that all cases of so-called 
chorea will never be found to be invariably associated w^ith any one 
anatomical lesion. 

Thus, passing to the actual results of post-mortem examination, we 
find a number of lesions recorded which evidently refer to cases of or- 
ganic disease of the nervous centres, which were merely attended with 
choreoid symptoms. 

Among these are enlargement of the odontoid process, effusions into 
the arachnoid, tumors in the substance of the brain, abscess in the cere- 
bellum, bony plates upon the spinal meninges, and many other entirely 
disconnected lesions. 



596 CHOREA. 

On the other hand there are cases on record, in which careful exami- 
nation has failed entirely to detect any material lesion, either of the 
nervous centres or of the other viscera, and in which the choreic move- 
ments were probably of a reflex character. 

Of late years, however, since this question has been subjected to 
more frequent and critical examination, there are certain lesions which 
have been found so frequently after death in fatal cases of true chorea, 
that the}^ must be regarded as possessing some definite connection with 
the disease. These lesions consist in certain morbid conditions of the 
heart, and of the nervous centres. 

In regard to the lesions of the heart, M. See {loc. cit., p. 890) states, 
after a careful examination of eighty-four autopsies, that "in most of 
the cases, and especially in those most strongly attested, chorea is the 
result of the rheumatic diathesis, and that it reveals itself by plastic 
inflammations of the cardiac membranes, of the pleura, and of the peri- 
toneum, with or without articular rheumatism." 

Bright, Copland, Todd,^ Kirkes,^ Nairne,^ Begbie,* were also among 
the first to call attention to the frequency of rheumatic endocarditis in 
connection with chorea. In an interesting article on -'Maniacal Chorea,"^ 
Tuckwell gives an analysis of the lesions in 34 fatal cases of chorea col- 
lected by himself In 25 of these the endocardium was found diseased, 
the presence of warty vegetations on the valves being especially alluded 
to in 20. Of the remaining 9, no mention is made of the heart in 5, 
and it is reported as healthy only in 4. The pericardium was found 
diseased onl}^ in 8 of the 34 cases. 

In Ogle's fatal cases (loc, cit., pp. 208 and 507), there were in 11 out 
of 17 instances more or less fibrinous deposit or granulations upon the 
valves or some part of the endocardium. In 2 cases only w^as the peri- 
cardium diseased. In the 14 fatal cases collected by Hughes (loc. cit.), 
vegetations were found on the valves of the heart in not less than 11. 

The results of careful auscultation, during life, come to support those 
of post-mortem examination. 

Hillier states {op. cit., p. 236) that, "of 37 cases in my note-books 
there was probably organic disease of the heart in 25, and in 4 others 
there was evidence of functional derangement, whilst in 8 only was 
there no sign of cardiac disturbance." 

Jules Simon writes from a large experience, and says: "I have been al- 
most always able to detect well-marked evidence of cardiac affection in 
chorea, in the shape of organic murmurs, hypertrophy of the heart, &c."^ 

In our own experience, evidences of rheumatic heart disease have 
very frequently been present in cases of chorea; and also in cases which 
have come under our care for organic disease of the heart, there has 
frequently been a history of previous attacks of chorea. 

1 Lumleian Lectures, 1849. 2 Medical Gazette, 1850. 

3 London Jour, of Med., 1851. "* Edin. Med. Jour., 1852. 

5 Brit, and For. Med.-Chir. Kev., Oct. 1867. 

6 Nouv. Diet, de Med. et de Chir. Prat. Art. Choree (quoted by Tuckwell, St. 
Barth. Hosp. Rep., loc. cit., p. 101). 



LESIONS OF THE SPINAL CORD. 597 

It is sufficiently evident, therefore, that in a large proportion of 
cases of chorea, some morbid condition of the endocardium is present. 
The particular lesion which has been usually found, consists of fine 
bead-like vegetations, which either fringe the border of the mitral 
valve, or are seated upon the auricular surface of its leaflets. 

These vegetations are in most cases readily detached from the valve, 
by lightly brushing them with the tip of the finger, or with a camel's- 
hair brush; and it has been supposed by some observers, as Ogle and 
Barnes, that they consisted merely of the fibrin of the blood, deposited 
in the agony of dissolution. We believe, however, both from the pre- 
vious occurrence of valvular murmurs in cases where such vegetations 
have been found, as well as from a careful study of the anatomical de- 
scriptions of their appearances, and the occasional presence of the posi- 
tive results of embolism, that these vegetations are produced by a pro- 
cess of endocarditis. 

We will, however, discuss the question of their connection with 
chorea, when we come to speak of the nature of that disease. 

In regard to the condition of the nervous system in fatal cases of 
chorea, there is at times no lesion appreciable, even on microscopic ex- 
amination, while on the other hand there is not unfrequently marked 
disease, either of the nervous tissue or of the meninges. 

Thus, in the 14 fatal cases collected by Hughes, the brain was healthy 
in 4, only congested in 3 cases; there was softening of the brain, with 
or without opacity of the membranes and serous effusion in 6, and in 
the seventh with opacity and congestion of the dura mater. 

In 11 of the 35 fatal cases collected by Tuckwell, the brain was found 
softened, and in 9 only is it reported as healthy. In the 16 fatal cases 
reported by Ogle, the brain was healthy in 6, much congested in 8, soft- 
ened in but 1, and anaemic in 1 also. 

It appears, therefore, that in a notable proportion of the cases upon 
record, positive organic disease of the brain, and especially in the form 
of softening, has been discovered. In a few instances embolism, or 
occlusion of the vessels by fibrinous masses, has been observed, either 
in the carotid artery (Ogle), or in the minute arterial branches leading 
to patches of softened brain-tissue (Tuckwell). We need, however, a 
large series of careful observations to determine more positively how 
frequently lesions of the brain occur, and especially in what proportion 
of cases embolism is present. 

The spinal cord has also been found softened with or without opacity 
and thickening of its membranes, though in a much smaller number of 
cases, probably in part because it has not been so frequently examined 
in such cases as the brain. 

Of the 16 fatal cases reported by Ogle, its tissue was congested in 5; 
there was slight softening in 2; in 1 the upper dorsal region of the cord 
was completely broken down and almost diflduent. In 2 cases the cord 
was examined by Mr. J. Lockhart Clarke, who found in one (loc. cit., p. 
221) that "in the lower part of the dorsal region, at the ninth dorsal 
nerves, the anterior columns were swollen, and formed a convex protu- 



698 CHOREA. 

berance of considerable size. Ir^ a transverse section of the cord carried 
through this part, and examined under the microscope, it was very evi- 
dent that extensive morbid changes had been going on, the white sub- 
stance had been softened, . . . and in two or three places there were 
circumscribed effusions of blood, surrounded by granular exudations, 
which had probably occurred before the effusions." Similar appear- 
ances were discovered in the lower dorsal region in the other case (loc. 
cit., p. 507). 

In a case already referred to, observed by Tuckwell, of rapidly fatal 
maniacal chorea in a lad of seventeen years of age, in addition to sev- 
eral patches of embolic softening of the brain, there was marked soft- 
ening of the spinal cord in the middle dorsal region. 

In 3 fatal cases reported b}^ Steiner (loc. cit.), there was increase in 
the connective tissue of the spinal cord; serous effusion in the spinal 
canal ; and congestion or effusion of blood in the membranes at the 
exit of the nerves. 

Finally, in the cases where embolism of the brain was observed by 
Tuckwell, there was also minute embolism of the kidneys. 

In a case of fatal chorea reported by Monckton,^ embolism of one 
brachial artery occurred, and, after death, large vegetations were found 
on the aortic valves. 

We will have occasion to refer again to these various anatomical ap- 
pearances when speaking of the nature of chorea. 

Symptoms; Course; Duration. — The disease may be general or par- 
tial : in the first case, it affects all the limbs, the face, and some of the 
muscles of the trunk; in the second it implicates only one side, the 
upper extremities, a single member, or a certain group of muscles. It 
happens not rarely that the choreic movements are limited to one side 
of the bod}^: thus in 80 cases of non-fatal chorea reported by Ogle (loc. 
cit., p. 488), the right side alone was affected in 24, whilst the left alone 
was affected in 20; and in 25 both sides were affected, though in some 
instances one or the other side was more involved than the opposite 
one. Of the 30 cases reported b}^ Gerhard (loc. cit.), no less than 15 
weue strictly unilateral, the choreic movements being confined to the 
right side in 10 instances, and in 5 to the left. In a large majority of 
the recorded cases of unilateral chorea, the right side was the affected 
one. It occasionally happens, as noted by Eussell {3Ied. Times and Ga- 
zette, 1868 and 1869) and Gerhard (loc. cit.), that a chorea, which be- 
gins as unilateral, may subsequently invade the opposite side and 
become general. Of 7 cases that we have seen, in which this point 
was noted, it was general in 4. and confined entirely to the right side 
in 1, and to the left in 2. We shall describe first the prodromes of the 
disease, then the invasion, and afterwards the symptoms as they exist 
in fully developed cases. 

Frodromic Syin-ptoms. — It is doubtful whether there are, as a general 
rule, any well-marked prodromic symptoms. The only ones that have 

1 British Med. Jour., 1866, No. 305. 



SYMPTOMS. 599 

been mentioned with any authority are irritability and peevishness of 
the temper, an unusual degree of impressibility, languor, debility, dis- 
turbance of the organic functions, exhibited by deranged appetite and 
an irregular state of the bowels, and, after a time, a certain quickness 
and irregularity of the movements, which mark the commencement of 
the characteristic symptoms of the malady. 

Invasion. — The onset of the disease is, as already stated, either sud- 
den or gradual, so that there may be several days or more before it 
reaches an^^ considerable degree of severity, or it may, particularly 
when the case has been of a sudden and energetic nature, reach its 
height in a few hours. In most cases, however, it begins with some 
unusual and singular movements in one of the upper extremities. The 
choreic movements are often observed first in the fingers, and at the 
same time or soon after, in the face. Sooner or later they increase in 
severity, and extend to the other arm, to the legs, and to the tongue, 
and the disease is fully developed. 

Symptoms of Confirmed General Chorea. — When the disease has be- 
come fully confirmed the movements are exceedingly diversified and 
irregular. The limbs are agitated by involuntary contractions of the 
muscles into every attitude possible for them to assume. The fingers 
are opened and shut, brought together or separated, without any regu- 
larity. The hands are flexed and extended upon the forearms, or pro- 
nated and supinated, whilst the forearms are flexed or extended upon 
the arms, and the arms moved at the shoulders into every imaginable 
position. Such are the irregularity and rapidity of the motions that it 
is often with great difficulty that the patient can seize anything with 
the hands, and when once the object is attained, he frequently cannot 
do with it what he wishes. This imperfect control over the hands and 
arms sometimes prevents the patient from carrying food and drink to 
the mouth, excepting with the utmost difficulty, and may make it neces- 
sary to feed the child. 

The inferior extremities are affected in the same way as the arms. 
AYalking is always more or less difficult, and in some severe cases im- 
practicable. The patient totters from side to ^ide, or walks rapidly a 
short distance, and then suddenly stops. Sometimes the progress is 
accomplished in a zigzag direction, and at others by fits and starts as 
it were, whilst in others again, the walk is rapid and sudden, almost a 
run. The child often falls while walking or running, either from meet- 
ing a slight obstacle, or in consequence of the irregular and imperfect 
muscular action. In some instances standing is impossible, the knees 
bending suddenly under the weight of the body. It was no doubt the 
peculiar irregular and dancing movements of the inferior extremities 
during the attempts to walk and stand, that gave to the disease its 
original name of St. Yitus's dance. 

The convulsive movements of the face and head are not less singular 
than those of the limbs. The face is distorted into all kinds of expres- 
sions, so that it assumes by turns that of the most opposite emotions, 
— sadness, terror, joy, or grief. The mouth is opened and shut, or its 



600 CHOREA. 

corners drawn apart, with the greatest irregularity; the tongue is oc- 
casionally protruded between the teeth, and sometimes moved rapidly 
in the mouth, so as to cause a clacking sound; the lower jaw is de- 
pressed and elevated, or moved in a lateral direction, and with such 
violence perhaps as to injure the tongue or teeth. In consequence of 
the irregular motions of the tongue and mouth, articulation becomes 
difficult and the child either stutters, or speaks slowly and badly, or 
can pronounce only monosyllables. In a case that occurred to one of 
ourselves, the movements of the mouth and tongue were so violent and 
uncontrollable that the patient, a boy nine years old, lost for three 
weeks all power of speech. He was at the same time unable to open 
or shut the mouth at will, or to swallow at the proper moment, so that 
in the act of feeding him, which became necessary from his entire 
want of control over the arms, the food was constantly spilled and 
spluttered about as though by an idiot. The act of mastication also 
was quite impossible, so that he could take nothing but fluids for a 
number of weeks. In another case also that occurred to one of our- 
selves, in a girl between eight and nine years of age, and which more- 
over was a relapse, the patient exhibited the same inability to feed her- 
self, and the same difficulty in regard to mastication, so that she had 
to be nourished for several weeks on soft food. The speech was like- 
wise greatly affected, it being very difficult to understand her muffled, 
thick, and indistinct utterance. 

Whilst the face and limbs are contorted as above described, the head 
is moved rapidly from side to side, or backwards and forwards, or un- 
dergoes constant rotation, and, in some instances, as in two that came 
under our own notice, all power over the muscles of the back of the 
neck is lost, and the head falls from side to side, or forwards, as in an 
infant. In severe cases the choreic movements affect the trunk also, 
so that the patient cannot lie upon a bed, but rolls and twists about the 
floor with such violence as to bruise and excoriate the skin. Degluti- 
tion is sometimes slightly embarrassed, and the child is obliged to 
swallow with great rapidity; in some few cases a peculiar loud cry, like 
that which occurs in hysteria, dependent apparently upon spasm of the 
larynx, has also been observed. The muscles of the external and in- 
ternal respiratory apparatus are rarely affected, though Eomberg nar- 
rates three remarkable instances, in which dyspnoea, loud whistling 
respiration, spasmodic contractions of the glottis, or hiccup, were pres- 
ent. Occasionally irregular action and palpitation of the heart are ob- 
served, and have been attributed to chorea of its muscular structure. 

In some cases, also, the sphincters of the bladder or rectum are par- 
tially paralyzed. Eetention of urine has been noticed in a few cases; 
and, on the other hand, the late Prof. William Pepper mentions having 
known incontinence of urine to alternate with chorea of the external 
muscles. 

The disease is unaccompanied by pain unless it be attended with 
some complication, and what is very singular and remarkable, the con- 



I 



SYMPTOMS. 601 

stant and often very violent muscular contractions do not seem to occa- 
sion fatigue. 

There is, however, frequently evidence of a want of muscular power, 
which may merely amount to an unusual susceptibility to fatigue on 
voluntary exertion ; or complete paralysis may be present, especially in 
the form of hemiplegia, in cases of unilateral chorea. This latter is by 
far the most frequent form of palsy in choreic patients, according to 
our own observation. It occurred in no less than 7 of Gerhard's 80 
cases — in 5 times on the right side, and in 2 upon the left. 

The general symptoms require some attention. The choreic move- 
ments are almost always increased by emotion, as terror, anger, con- 
trarieties, and by the consciousness of being observed. Sleep generally 
suspends them entirely. In very bad cases they are said to produce in- 
somnia, or to wake the child frequently in the night. The intelligence 
is rarely affected, except in very severe and long-continued attacks; 
though some authors appear to have met with frequent instances of 
impairment or perversion of the intellectual faculties. It is said that 
idiocy is apt to occur in cases which last for a number of years. The 
temper is often irritable and capricious. General and special sensibility 
commonly remain natural ; though in some cases, impairment of general 
sensibility of the parts most convulsed, even amounting to anesthesia, 
is noticed. In simple, uncomplicated attacks, the pulse, as a rule, re- 
mains natural: the appetite is preserved; there is no unusual thirst, 
and the bowels continue regular. 

The urine has at times been observed to be of unusually high specific 
gravity, and to contain an excess of urates and oxalates. These con- 
ditions do not, however, appear to be at all constant or characteristic. 

In a considerable proportion of cases of chorea (see statistics on page 
596), a bruit is heard on ausculting the heart, usually of low pitch, and 
not very great intensity. In some cases this is undoubtedly due to the 
vegetations so frequently found on the valves of the heart in this dis- 
ease, but in others it appears to be rather due to the anaemic state of 
the blood: and in those cases where palpitation exists, it may be due 
to the irregular contractions of the walls of the heart. It has also been 
noticed that these murmurs in chorea are often transitory, and even 
intermitting. 

The course of the disease is acute or chronic. In a large majority of 
cases it is acute, the symptoms becoming more and more violent until 
they reach their height, when they remain stationary for a time, and 
then subside and disappear under the influence of treatment, or in the 
natural course of the malady. It has been frequently noticed that 
w^hen an acute febrile or inflammatory disease is developed during the 
course of chorea, the spasmodic movements are very apt to diminish or 
entirely cease for the time. In fiatal cases the symptoms are constantly 
aggravated; the movements become so violent as to make it necessary 
to secure the child in bed, or in a strait-jacket; the patients, deprived 
of sleep, become feeble and emaciated ; the respiration becomes diffi- 
cult; intelligence is abolished ; the pupils are contracted; and the child 
dies. 



602 CHOREA. 

The duration is irregular, varying in acute cases between one and 
three months. The average duration is probably about six or nine 
■weeks. In very slight attacks it may be much less. The duration of 
chronic cases is from months to years. In fatal cases the duration is 
sometimes very short. In one it was only nine, and in another twenty- 
seven daj'S. The local forms of the disease are often peculiarly intract- 
able, and last manj- years. 

Relapses. — Relapses are quite common, and are said by Trousseau to 
be shorter than the original attack. We have, however, in a few cases, 
observed that the relapse was much worse than the first attack. In one 
case in particular, the relapse was one of the most violent and prolonged 
attacks that we have seen. MM. Eilliet and Barthez state they occurred 
in six out of nineteen cases seen by them. The relapses in these cases 
occurred once, twice, and three times. M. See {loc. cit., p. 408) says 
that it is not uncommon, after some weeks of respite, or several months 
of apparent recovery, to see the disease reappear with renewed intensity, 
and be thus repeated twice, thrice, and even seven times in succession. 
Out of four patients, at least one, he states, remains thus under the in- 
fluence of the disease. Of 158 cases he counted 37 relapses, of which 17 
were arrested after the second attack; 13 suffered a third, and 6 a fourth 
attack; and, lastly, one had seven distinct seizures, each one of which 
was separated from the following by a well-marked interval. In 46 
of Ogle's cases in which this point was noted, previous attacks had 
occurred in 25 : in 5 of which there had been 2 previous attacks, and 
in 1 no less than 7. According to Gerhard, relapses, like the primary 
attacks, occur most frequently in spring. 

Nature of Chorea. — In considering the essential nature of chorea, 
it is evident that there are two points of importance to be determined, 
namely, the precise portion of the nervous system involved, and the 
nature of the morbid change in this part. 

Before alluding to the views which have been entertained in regard 
to the first of these questions, we would refer to the very great irregu- 
larity which exists in different cases in the extent and distribution of 
the choreic movements. Thus it frequently happens that the disease is 
strictly confined to one or the other side of the body, or it may be en- 
tirely symmetrical. In other cases the muscles of the head and neck 
may almost or quite escape, while both legs and one or both arms are 
affected. Or, on the other hand, the choreic movements may first ap- 
pear and remain most severe in the muscles of the face, mouthy and 
tongue. It seems probable to us, therefore, that there is no one special 
portion of the motor centres which is exclusively the seat of lesion in 
all cases of chorea. In the great majority of cases, however, the symp- 
toms are so far uniform that the muscles of the face and tongue, as well 
as those of the extremities, are affected, and the only peculiarity is that 
the irregular movements may be confined to one or the other side, a 
circumstance susceptible of ready explanation. 

Marshall Hall considered chorea as an affection of the true spinal 
system, and possibly in some cases where the choreic movements are 



NATURE OF CHOREA. 603 

limited to the extremities and symmetrical, this supposition may be 
correct. 

Id the vast majority of cases, however, it is undoubtedly necessary to 
locate the seat of disturbance in chorea at a higher point in the cerebro. 
spinal axis, one above the decussation of the anterior pyramids, and 
probably in or near the corpora striata. Among the arguments which 
lead to this view, man}- of which have been advanced by J. Hughlings 
Jackson^ and Broadbent,- who strongly uphold it, may be stated the 
following : That the ranscles of the face are very frequently affected by 
the choreic movements; that in the great majority of cases the move- 
ments cease during sleep; that the affection is frequently limited to one 
side of the face and body, and that the spasmodic movements not rarely 
terminate in complete hemiplegia. In a footnote (loc. cit., p. 93) Tuck- 
well says: "It is just to Dr. Todd's memory to add, that he long ago 
{Lancet, 1843, vol. ii, p. 463) showed that the choreic phenomena cannot 
be explained by the hypothesis which refers them to irritation of the 
spinal cord. He says: 'The hemiplegic tendency is utterly inexplica- 
ble according to that view. The affection of one-half the body would 
alone refer to some point above the decussation of the pyramids as the 
seat of irritation.' " The supposition of Carpenter and others that the 
cerebellum is the seat of the disturbance in chorea, was based upon the 
view that that organ possessed the chief power of co-ordinating muscu- 
lar movements. Eecent researches into the functions of the cerebellum, 
as well as the arguments which have been adduced above, render this 
supposition untenable. 

The further question now remains as to the condition into which the 
affected j)art of the motor centres is brought, in order to produce the 
phenomena of chorea. And it is especially in regard to this point that 
the investigations of Jackson and Broadbent, above referred to, are of 
80 much value. These pathologists, and particularly the latter, have 
called attention to the fact that the choreic phenomena are symptomatic 
merely of the seat of the disease, and that the only essential condition 
of their production is an impairment of Vigor and instability of the 
sensori-motor ganglia, a condition which may probably be induced in 
different ways. 

We are now prepared to consider the manner in which the various 
causes of chorea may be supposed to act. 

We have already seen that in a certain number of cases chorea is in- 
dependent of any appreciable lesion of the nervous system. In some 
of these cases it is possible that the impaired nutrition of the motor 
centre maj' result from an altered and ansemic state of the blood ; and, 
indeed, it appears to us quite as reasonable to explain a certain class 
of cases of chorea in this manner, as to apply the same explanation to 
analogous cases of paralysis. 



1 Keynolds's Syst. of Med., Art. Chorea, vol. ii, p. 127, footnote ; and Med. Times 
and Gaz., March 6th, 1869. 

2 British Med. Jour., 1869. 



604 CHOREA. 

It is probable, also, that in another group of cases, chorea may be 
reflex in character, and depend upon a different degree of that peculiar 
action upon the motor centres which produces reflex paralysis, whether 
by exhausting their excitability or by causing a reflex spasm of their 
vessels. This view is maintained by Broadbent (loc. cit.) as well as by 
Eadcliffe,^ who states that irregular choreic movements may be produced 
not only by injury of certain parts of the nervous system, but by injury 
of certain nerves at a distance from the nervous centres, the portions 
of the cerebro-spinal axis which are concerned in the development of 
such movements, being affected by reflex action. 

It is probable that if this mode of production be admitted, it will serve 
to explain a large number of cases of chorea, both where the source of 
irritation is at a distance (as in cases of pregnancy, or where there are 
worms in the intestinal canal or, as we have known in one case, where 
a splinter was lodged in the matrix under a finger-nail) and where it is 
seated in immediate connection with the nervous centres. As instances 
of the latter kind, may be suggested such conditions as thickening of 
the meninges of the brain or spinal cord, and the presence of bony 
spiciilse developed in the meninges. 

Finally, we must admit as a cause of chorea, primarj' alterations of 
the tissue of the sensori-motor ganglia and adjacent parts; the degree 
of disease not being so great as to abolish entirely their function and 
produce paralysis, but only sufficient (as for instance would be secured 
by an early stage of softening) to weaken it and render it unstable. 

It will be seen from the foregoing remarks that we deem it impossi- 
ble, at least in the present state of our knowledge upon the subject, to 
consider the cause and mode of production essentially the same in all 
cases of chorea, and that we are disposed to admit the existence of 
cases due to mere anaemia and impaired nutrition, or to an altered 
state of the blood; of cases due to reflex irritation, in both of which 
classes of cases, some minute and as yet inappreciable lesion may 
exist; as well as of cases which are due to primary material alterations 
of the sensori-motor ganglia. 

We have already, in considering the causes and anatomical appear- 
ances of chorea, had occasion to dwell upon the close connection which 
exists between it and rheumatism, and before leaving the present sub- 
ject it is desirable to refer to the various explanations which have been 
offered of this circumstance. Among these, the most important and 
interesting is that of Kirkes,^ who, noticing the frequent presence of 
vegetations upon the valves of the heart in fatal cases of chorea, was 
led to suggest that very small fragments of fibrin might be detached 
from the valves, and entering the circulation cause temporary obstruc- 
tion of the minute capillaries of the nervous centres, producing irrita- 
tion and impaired nutrition. This theory, which attributes the pro- 
duction of chorea to embolism, has been accepted by J. Hughlings Jack- 

1 Keynolds's Syst. of Med., Art. Chorea, vol. ii, p. 126. 

2 Med. Times and Gaz., 1863, vol. i, pp. 636 and 662. 



NATURE OF CHOREA. 605 

son (Joe. cit.), by Savory/ by Tiickwell (loc. cit.), and, in part at least, 
by Broadbent (loc. cit.). 

It is supported strongly by the facts that continued observation of 
cases of chorea has shown even more clearly the very frequent exist- 
ence of cardiac murmurs during life, and of vegetations upon the valves 
after death; that complete paralysis, usually in the form of hemiplegia, 
frequently follows the choreic movements; that in many fatal cases 
there is found just such cerebral softening as follows embolism; and, 
finally, that in a few cases, already referred to, the existence of embol- 
ism has been actually demonstrated. 

There have, however, been numerous objections advanced against 
this theory, the most powerful of which are urged by Barnes (he. eit.) 
and Ogle (loc. cit.). Thus it has been objected that, on the supposition 
of numerous minute fragments of fibrin circulating in the blood and be- 
coming impacted in the minute capillaries, it would be difficult to ex- 
plain the fact that chorea is so frequently unilateral, or even localized in 
a single group of muscles. It must be remembered, however, in answer 
to this, not only that in some cases of fatal chorea embolism of single 
large arterial branches has been found, but that the number of minute 
fragments of fibrin detached from the heart's valves may be very small, 
and that it is quite supposable that they should in some instances nearly 
all pass into the innominate, or the left carotid artery, and thus be chiefly 
distributed to one side of the brain. It may be mentioned also in this 
connection, that it is especially in these cases of unilateral chorea that 
the affection is succeeded by paralysis, such as might readily follow in 
case of embolism. 

Again, it has been objected that if chorea be invariably dependent 
upon embolism, the results of this accident must be of a very transient 
and trifling character, since in so great a majority of cases the disease 
terminates in complete and permanent recovery. The weight of this 
objection must be admitted, and yet Tuckwell fairly remarks in answer 
to it, that the "mere fact of recovery is not enough to condemn the 
notion of embolism. On the other hand, the very frequent presence of 
a cardiac murmur, even in the milder attacks of chorea which recover, 
would rather dispose me to look for the same exciting cause in the mild 
as in the severe cases, viz., embolism." It is evident also that if the 
supposed embolus were minute, and therefore obstructed only a very 
small vessel, a collateral circulation might soon be established and re- 
store the nutrition of the area affected. 

Another objection advanced by Ogle (loc. cit., p. 232) is, that in other 
cases of capillary embolism the symptoms produced are not those of 
chorea, but rather of pysemia or of gangrene. It is quite evident, how- 
ever, that these symptoms alluded to (which are met with for instance 
in ulcerative endocarditis) are due, as remarked by Savory and Tuck- 
well, not to the mere capillary embolism, but to the concomitant septic 
condition of the blood. In this connection, reference maj'' be made to 
the elaborate experiments of Panum as to the results of embolism (Arch. 

1 St. Barth. Hosp. Rep., vol. i, 1865, p. 107. 



606 



CHOREA, 



/. Path. Anat., xxv, 308, 433; Syd. Soc. Year-Book, 1863, p. 211), in which 
he demonstrates that embolism of the vessels of the brain and medulla 
oblongata is followed by tetanic symptoms. 

This extremely interesting question cannot be considered as definitely 
settled; there is still needed a series of careful examinations in regard 
to the various points under discussion. It appears to us, however, con- 
clusively shown that, in a certain number of cases^ the peculiar irrita- 
tion and impaired nutrition of the sensori-motor ganglia, which leads 
to the development of the choreic phenomena, are due to embolism of 
the vessels supplying these parts. We have, however, already ex- 
pressed our opinion that, at present at least, there must be admitted 
two other classes of cases of chorea, due primarily to alterations in the 
blood and to reflex irritation respectively. It is quite possible, there- 
fore, that in some instances rheumatism induces chorea indirectly, 
either by causing anaemia and impaired nervous vigor, or by causing 
inflammatory lesions, as of the spinal meninges or sheaths of spinal 
nerves, which may serve as the foci of reflex irritation. 

Diagnosis. — The diagnosis of chorea cannot be attended with any 
difficulty, and we shall therefore make no remarks upon it. 

Prognosis. — Idiopathic simple chorea in young children is rarely a 
fatal disease. INevertheless, even under these circumstances, it some- 
times terminates fatally, and usually from exhaustion. Thus MM. 
Eafz, Legendre, and Killiet and Barthez have each met with an in- 
stance. M. See {loc. cit., p. 406) states that of 158 cases, 4 passed into 
the chronic condition, and 9 proved fatal. Dr. Copland states that he 
has met with 3 or 4 fatal cases, that Dr. Prichard has recorded 4, and 
that Dr. Brown refers to 3 in his practice; but he does not inform us 
whether they were idiopathic, complicated, or symptomatic. We have 
already referred to the list of 14 fatal cases, of which the autopsies 
were reported by Dr. Hughes {loc. cit.); and to the 34 additional fatal 
cases collected by Tuckwell (loc. cit.). Dr. J. W. Ogle has lately {Brit, 
and For. Med.-Chir. Eev., January and April, 1868) published the de- 
tails of 19 more fatal cases ; and from the same source we quote the follow- 
ing table as exhibiting the mortality from this disease in Great Britain 
during 23 years. 





Deaths from Chorea. 




Deaths from Chorea. 


1839, . 


. 54 


1855, 69 


1840, . 


. 25 


1856, . 




. 59 


1841, . 


. 28 


1857, . 




. 44 


1842, . 


. 19 


1858, . 




. 53 


1847, . 


. 89 


1859, . 




. 55 


1848, . 


. 38 


1860, . 




. 66 


1849, . 


. 34 


1861, . 




. 71 


1850, . 


. 60 


1862, . 




. 62 


1851, . 


. 77 


1863, . 




. 63 


1852, . 


. 73 


1864, . 




. 73 


1853, . 


. 67 


1865, . 




. 88 


1854, . 


. 48 


Total during 2. 


i yeai 


rs, 1255. 



It is quite possible, however, that many cases of organic disease of 
the nervous system merely attended with irregular choreoid muscular 



TREATMENT. 607 

movements have been included in these reports. On the other hand, 
out of 84,332 deaths at all ages occurring in this city during seven con- 
secutive years, but 3 are attributed to chorea. It must not, however, 
we think, be positively inferred from this that severe and ftxtal chorea 
has been really so rare among us; since, during the same time, there 
are reported in addition to the deaths from convulsions, 79 deaths from 
cramps, a vague and most improper term, which, in all probability, in- 
cludes a certain proportion of cases of chorea. 

In regard to any special rules in prognosis to be deduced from a study 
of the fatal cases, it may be observed that their average age is consid- 
erably greater than that of ordinary mild chorea. Thus in 17 out of 
Ogle's 19 fatal cases, but two were under the age of ten; the average 
being 15|-ths years. 

So too in 32 of Tuckwell's 34 fatal cases, 21 were at or above the age 
of fourteen, and 6 of this 21 were at or above the age of twenty. 

The duration of the case scarcely seems to have a direct bearing upon 
its fatalit}^. It is true that in cases which have passed into the chronic 
form and persisted for several months, the prospect of being able to 
effect an entire cure diminishes, but still such patients may live very 
many j^ears, and ultimately die only from some intercurrent disease. 
And, on the other hand, death has been known to occur as early as the 
end of the first week. Of course the existence of any serious compli- 
cation, and perhaps especially of marked cardiac disease from previous 
rheumatic attacks, renders the prognosis unfavorable. 

In conclusion, whenever, in a case of chorea, the convulsive move- 
ments become incessant, and the respiration embarrassed, and still 
more when subsultus tendinum takes the place of the choreic move- 
ments, a fatal termination is greatly to be apprehended. 

Treatment. — Many different plans of treatment, and a great variety 
of drugs have been proposed for the cure of the disease under consid- 
eration. These facts alone may serve to teach us that the effects of 
treatment are not clearly appreciated, and also, when taken in connec- 
tion with the circumstance that fatal cases are rare, that the disease 
tends naturally to recovery in a good proportion of the cases. This 
feature of the natural history of the disease is shown also by the evi- 
dence given by Dr. Bardsley, who mentions, that in the Manchester 
Infirmary, notwithstanding the variety of treatment adopted by suc- 
cessive practitioners, an incurable case had not presented itself in the 
course of thirty-three years. (^Tweedie's Lib. Pract. Med., Am. ed., vol. 
ii, p. 46.) 

The only rules to be laid down for its treatment are those which 
apply to all the convulsive affections depending on functional disorder 
of the nervous system, and on disordered states of the general health, 
connected with a faulty condition of the functions of digestion and as- 
similation. These are attention to the general health, and especially a 
careful regulation of the diet and other hygienic conditions of the 
patient, the removal of any local derangement or disease that may exert 
an unhealthy influence upon the nervous system, the use of tonics and 



608 CHOREA. 

iron, and the employ ment of such remedies as have been found to exert 
a controlling effect upon spasmodic and convulsive affections generally, 
and upon this disease in particular. 

We shall consider, under different heads, the various means that have 
been recommended, endeavoring in the course of our remarks to dis- 
tinguish the cases to which each remedy is best adapted. 

Purgatives. — This class of remedies has been extensively employed 
and often exclusively relied upon by some verj' high authorities, especi- 
ally the English. When relied upon exclusively in the treatment, an 
active cathartic is given every day, or every second or third day; and 
there can be no doubt that man}^ cases have recovered under this plan. 
In our own practice we must say that the treatment by cathartics 
alone has never succeeded well, and we have only used them of late to 
such an extent as was necessary to secure a soluble and healthful condi- 
tion of the bowels. When, therefore, the stools are natural and health- 
ful in all respects, we do not think it proper to employ powerful purga- 
tives in the treatment of the disease. We resort to them only when 
there is constipation, or when the discharges present some unnatural 
appearances as to color, odor, &c. Under the latter circumstances we 
may resort to any of the somewhat active cathartics, as cream of tartar 
and jalap, sulphate of magnesia, rhubarb, aloes, &c. When the dis- 
charges from the bowels are clay-colored, or dark and offensive, when 
the mouth is pasty, the tongue loaded with a thick yellowish fur^ and 
the breath heavy, it is proper to employ a mercurial. Dr. Copland 
advises that we should commence with the exhibition of a full dose of 
calomel, either alone or with other purgatives, or followed by them in 
five or six hours. He adds that the doses of calomel ought not to be 
frequently repeated in the disease, and thinks that it is not serviceable 
"to continue purgatives long, without either exhibiting them with a 
bitter tonic or antispasmodic remedy, or with both, or alternating them 
with those remedies." 

Antispasmodics are amongst the most important remedies we have to 
023pose to the disease. The weight of evidence seems to show, indeed, 
that they, in conjunction with a moderate use of purgatives, of tonics, 
especially ferruginous tonics, and of certain particular remedies, and 
with careful regulation of the hygienic conditions of the patient, ought to 
constitute the treatment in the great majority of cases. Of the various 
remedies of this class that have been employed, those which have ex- 
erted the most beneficial influence are valerian, assafoetida, oxide of 
zinc, caniphor, the root of the cimicifuga or black snakeroot, and the 
bromide of potassium. 

Particular Remedies. — Of the remedies belonging to this class, the one 
most employed in this city at present is, we think, the cimicifuga. This 
was first introduced into use by Dr. Jesse Young, and is now exten- 
sively employed and much relied upon. Dr. Wood {Pract. of Med., vol. 
ii, p. 755), says : " I have in repeated instances found it of itself ade- 
quate to the cure of the disease." We have employed it ourselves quite 
frequently in primary cases, and in two cases of relapse. In several of 



TREATMENT. 609 

the former the children recovered entirely und^fir its use; in some, 
however, it failed to do any good, and recover}^ took place under the 
use of iron, arsenic, the sea-bath, and in the course of time. In the 
two relapsed cases, the patients recovered finally under the use of 
the cimicifuga, iron, cod-liver oil, and good diet. One of the cases 
that recovered under its use was among the w^orst we have ever met 
with. It was that of a boy of nine years, in whom the disease went 
so tar as to destroy all power of locomotion. The child was unable 
even to stand. At the same time, the movements of the lips, cheeks, 
and tongue were so violent and irregular, and so little under the 
control of the will, that the power of speech was lost entirely for a 
period of four or five weeks. The choreic spasm appeared to affect 
even tlie muscles of deglutition, so that the act of swallowing was 
often difficult and uncertain. Mastication also was impossible, and the 
child was unable to carry anything to its mouth, rendering it neces- 
sary to feed him, as one would a baby, with soft solids and fluids. 
During some two months, the muscles at the back of the neck were 
so weakened that the head could not be lifted from the pillow or held 
direct, but fell from side to side or forwards like that of an infant. The 
condition of the child was altogether one of the most complete and 
distressing helplessness. During the first month of the case, it was 
treated with active cathartics, chiefly very large doses of cream of 
tartar and jalap, and with iron, but as the symptoms became worse and 
worse, the cathartics were abandoned except so far as to maintain by 
the occasional use of rhubarb and senna, a soluble state of the bowels, 
which were very much disposed to constipation. The patient was now 
put upon the use of decoction of cimicifuga, of which he began with 
four ounces, soon increased to half a pint per day, made in the propor- 
tion of half an ounce to the pint. The iron was continued. Under 
this treatment he very soon began to amend, and in two weeks showed 
a very decided improvement. Cod-liver oil was now added to the iron 
and cimicifuga, and in six weeks he was in great measure restored to 
health, and in the end recovered completely. In another case almost 
as bad as this, the patient finally recovered under the same treatment. 

The cimicifuga is given in powder, tincture, decoction, or fluid ex- 
tract, and should be continued for several weeks in gradually increasing 
doses, until sotue visible effect is produced, as nausea, headache, vertigo, 
or disordered vision. The usual doses are from half a drachm to a 
drachm of the powder, from one to two ounces of the ofiicinal decoction, 
and one or two drachms of a saturated tincture, given three timies a day. 
For our own part we prefer the decoction, of which we give to children 
of eight or nine years old, from four ounces to half a pint a day, made 
in the proportion of half an ounce of the root to a pint of boiling water. 
Prepared in this way, it is not a disagreeable drink, and is usually 
taken without much objection. 

The bromide of potassium in full doses has in some cases in our ex- 
perience proved of marked benefit. We have used it especially in those 

39 



610 CHOEEA. 

cases which were connected with rheumatism as a cause, and have then 
frequently administered it in combination with the iodide of potassium 
and the iodide of iron. 

Some French authors recommend chiefly valerian, oxide of zinc, and 
assafoetida. Of these the one which has the highest reputation is valer- 
ian, and from the evidence adduced in its favor there can be no doubt 
that it exerts a very beneficial effect upon the disease. It may be given 
in the form of powder, infusion, or fluid extract. The dose of the powder 
is from twelve to eighteen grains in the day, to commence with, to be 
rapidly increased to several drachms, as the stomach becomes accus- 
tomed to it. It may be given in honey or preserve-syrup. We should 
prefer the fluid extract, of which half a teaspoonful may be given to a 
child eight or ten years old, three times a day, and the quantity gradually 
increased. The oil of valerian is employed by some practitioners. Oxide 
of zinc is given in doses of a grain every three hours to children eight 
years old, and is much relied upon by some practitioners. Assafoetida 
is recommended both by English and French writers. It is best given 
in pill, on account of the nauseous taste of the mixture. Two three- 
grain pills may be given to a child of four or six years of age, three 
times a day. Dr. Bardsley gave it by injection, in combination with 
laudanum, every evening, after using musk and camphor through the 
day. 

Narcotics have been recommended by some writers. Those which 
are most employed are opium, belladonna, stramonium, and cannabis 
Indica. Substances of this class are seldom, however, made the basis 
of treatment. Opium is useful in some cases in which the agitation is 
very great, so that the sleep of the child is much disturbed, but it is 
seldom necessary except as an adjuvant to other means; and the re- 
mark applies equally to other remedies of the class. 

Arsenic. — There is no remedy in regard to whose curative action in 
chorea testimony is more unanimous. Eomberg and Begbio speak of 
it as curing the affection in as short a time and with even greater 
certainty than any other remedy; and Trousseau also testifies to its 
good effects, but adds that it has the disadvantage of being difficult of 
administration, owing to its irritant properties. Gerhard {loc. cit.) also 
speaks of it as having proved of marked benefit in his hands. Dr. Ead- 
cliffe, who has met with the same difficulty in maintaining the use of 
full doses of this remedy for any length of time, has tried with appar- 
ently marked success the hypodermic injection of Fowler's solution. 
He was irst led to emplo}^ this in cases of chronic local chorea in adults, 
where the injection of doses of Fowler's solution, varying from five to 
fourteen minims, produced a speedy cure. He has also employed it 
successfully in two cases of general chorea, the duration being twenty- 
eight and thirty-two days respectively. 

The usual manner in which we have administered it is in the form of 
Fowler's solution, given in the ordinary doses, and immediately after 
eating, and steadily persisted in until some evidence of its constitutional 
effects are produced. By carefully watching for these, and immediately 



TREATMENT. 611 

reducing the dose until the signs of irritation have passed away, and 
then again cantioiislv increasing it, we have usually been able to ad- 
minister it without serious inconvenience, and with excellent results in 
a large proportion of cases. This preparation may also be advantage- 
ously combined wnth the bitter wine of iron. 

S^ri/chnia. — Trousseau recommends more highly than any other plan 
of treatment, the use of sulphate of strychnia in gradually increasing 
doses, until the extreme limit of tolerance is reached. He begins by 
giving gr. ^rVth twice or thrice daily, to children between five and ten 
years old, and cautiously increases this dose until it reaches about gr. 
f th in twenty-four hours. The results obtained by this treatment in 
Trousseau's hands certainly appear good, but the risk attending it and 
the care demanded to prevent accidents are so great, that we should 
prefer some of the equally successful and less dangerous methods. It 
appears, however, that other observers, as West, have obtained good 
results from its use in doses much smaller than those recommended by 
Trousseau, not exceeding gr. 37^^th thrice daily, for children of eight or 
ten years of age. 

Conhnn maculatum, given in the form of the succus conii, has been 
highly recommended by Dr. John Harley {The Old Vegetable Neurotics^ 
London, 1869), in the treatment of chorea; and a certain number of 
cases have already been reported of its successful administration. Dr. 
Harley prescribes the succus in the doses of 20 or 30 drops for a child 
of six months old ; a drachm for one over two years old -, and from one 
to two drachms at ten years of age. In explaining the use of doses so 
large as these, he insists upon the fact "that hemlock given in doses 
which fail far short of producing its proper physiological action, is use- 
less for the treatment of the diseases to which it is adapted." 

Stimuli. — The well-known views of Dr. Radcliflfe upon the pathology 
of spasmodic affections, have led him to recommend the free use of 
alcoholic drinks, to the point of obtaining their decidedly sedative 
action on the economy, as the foundation of a rational treatment in 
chorea. 

Without being prepared to adopt this as a regular plan of treatment 
for ordinary cases of the disease, we should certainly be disposed to ad- 
minister alcoholic stimuli whenever the symptoms indicated the ap- 
proach of nervous exhaustion. 

Tonics. — Wlienever the disease occurs in debilitated and anaemic indi- 
viduals, remedies of this class are evidently necessary, and prove of 
great efficacy. The ferruginous preparations are those mdfet clearly 
indicated under the circumstances; and, indeed, there are many author- 
ities, as Watson, Elliotson, and others, who consider the preparations 
of ii'on sufficient, of themselves, to cure almost all cases of chorea. Any 
of them may be selected. The best are the subcarbonate, Yallet's 
pills, the syrup of the iodide, and the pure metallic iron (ferrum per 
hydrogen). Quinine is also recommended w4ien the patient is feeble 
and weak. It may be given alone or in combination with iron. The 
citrate of iron and quinine would form a very good prescription under 



612 CHOREA. 

the circumstances mentioned. Cod-liver oil is an admirable remedy 
when the child is thin and weak, and especially when there is cause to 
suspect any tubercular predisposition. 

A great variety of remedies besides those we have mentioned have 
been employed, and have more or less evidence in their favor. Amongst 
them are sulphate and iodide of zinc, nitrate of silver, subnitrate of bis- 
muth, iodine, calabar bean, and a host of others which it is useless to 
enumerate. The sulphate of zinc has undoubtedly proved efficacious 
in some instances. About two grains may be given at first three times 
a day, and gradually increased to six or eight if the stomach bears the 
remedy well. 

External Remedies. — The cold plunge and shower bath as well as cold 
affusions to the nape of the neck and along the spine have been frequently 
employed as adjuncts to the internal treatment, and are of unquestion- 
able value in many instances. The cases in which they are used should, 
however, be selected. They ought not to be employed unless followed 
by full reaction, nor unless the child is w^illing to take them. When the 
use of the bath terrifies or shocks the patient greatly, it cannot be proper. 
A warm or tepid bath used once a day, or every second day, would al- 
wa3's be useful in promoting the general health, when the cold bath is 
not borne well. Ether spray has been recommended by Lubelski {Gaz. 
Hehd., April 19, 1867), as an application along the spine, and a number 
of cases in which its use was successful have been placed on record. 

Sulphurous baths have been recommended and emploj^ed with much 
success, by M. Baudelocque of Paris. A rapid and definite cure was 
obtained in 58 out of 65 cases. Thirty drachms of sulphuret of potas- 
sium are added to each bath, which is employed for at least one hour 
daily, at a temperature of 91°. Generally amelioration occurs after 
the second or third bath, but sometimes not until after twelve or 
fifteen days, a mean of twenty-two days having served for the cure of 
fifty out of fifty-seven cases. Where the cure is retarded, it ordinarily 
depends upon the patient's powers being lowered by other remedies or 
insufficient diet, upon irritation of the skin induced b}^ the bath, or 
upon acute ii'ritation of the internal serous membranes: circumstances 
contraindicating the baths while they continue. The conjunction of 
other remedies retards rather than aids the cure. Deducting the cases 
in which the bath was improperly used under the above circumstances, 
there remain but nine true failures in eighty-one cases, these being 
almost all recent or rheumatic choreas. (See on Chorea, Banking's Ab- 
stract, 1^0. 16, p. 51.) 

Counter-irritation to the spine, in all its shapes, from pustulation with 
tartar emetic, issues, and blisters, down to frictions with coarse towels, 
has been proposed and employed in the treatment. The use of any 
but the milder remedies of this class is unnecessarily harsh and cruel, 
except when the disease is evidently dependent upon an affection of 
the brain or spinal marrow. The great majority of cases will recover 
perfectly well without a resort to such violent means, and they ought 
therefore to be avoided. 



TREATMENT. 613 

Electricity has been resorted to, and apparently with good effects in 
some instances, and it might therefore be tried when other and simpler 
means fail, or in conjunction with these means. In cases where the 
spasmodic movements are constant and persistent despite the use of in- 
ternal remedies, the inhalation of anaesthetics has been tried, but with 
uncertain results. 

In violent cases, it is of course desirable to confine the patient to bed; 
and it may be necessary to have padded sides made for it to prevent 
him from dashing himself out of bed in his uncontroHable and violent 
movements. In such cases it may even become necessary to employ 
padded splints, or to envelop the bodj" with bandages carefully ajiplied 
over layers of wadding, so as to secure the legs together, and to confine 
the arms by the sides. 

Gymnastic Exercises. — M. See {loc. cit., p. 481) sa^^s that this method 
is one of the best that has been employed. He states that it was recom- 
mended by Darwin, and then by Mason Good, and was first employed 
by Louvet Lamarre in one case, after which it fell into oblivion until 
some of the physicians of the Children's Hospital, at Paris, and amongst 
others, MM. Bouneau, Baudelocque, Guersant, and Blache, ^'struck, no 
doubt, like myself, with the good effects of gymnastics in scrofula and 
other cachectic diseases, and taught especially by the effects of mus- 
culation on the general health, conceived the idea of applying tins treat- 
ment to nervous diseases, and particularly to chorea, which, besides 
the perturbation of the nervous system, is so often attended with dis- 
orders of nutrition and of the functions of organic life. To put a slop 
to this state of languor, to re-establish at the same time the equilibrium 
of the movements, which are rather irregular than convulsive, to en- 
deavor, in fine, by regulating the contractions, to break up their viti- 
ated habit, — this is the triple object sought to be attained by gymnas- 
tics. Be it theory or empiricism, success crowned these pi-evisions, 
and proved the utility of the new treatment, of which we are about to 
study the methods and its consequences." M. See says, that to com- 
mence the treatment, we must prescribe first simple and cadenced 
movements, and exercise at the same time the larynx by metms of 
singing. ''To place the child in a vertical position, make it flex and 
extend the knees, touch the ground, stretch out and bend the arms, 
harmonizing at the same time these various movements by regulated 
singing, — such are the first means by which to replace the contractions 
under the power of the will. This end will be so much the more rap- 
idly attained, as the attention of the patient is the less distracted, its 
intelligence the less changed, and its temper the less capricious; so also 
is it often impossible to succeed unless we first obtain control over the 
patient by kindness and gentleness. 

"After reaching this point, we may attempt walking, regulated to a 
slow or quick step, running, jumping, hanging by the arms, or other more 
complicated movements, always graduating them to the degree of the 
disease, watching them most carefully, and repeating them daily with- 
out prolonging them beyond fifteen or twenty-five minutes, in order to 



614 CHOREA. 

avoid muscular fatigue and palpitation of the heart, which occur some- 
times when the exercises are too long continued. 

" With these precautions, and no matter how severe the symptoms, 
we may, after a few lessons, and sometimes after the first, and at latest 
after the fifth or sixth, perceive a manifest change in the abnormal mo- 
bility, which is usually so rapid that we are generall}^ able to decide, 
after the first eight days, as to the efficacy of the treatment. When, 
after this length of time, the patient can neither stand erect, walk in 
a straight line, nor hang by the arms, there is reason to fear that the 
method will fail ; it is at least certain that it will be tedious and dif- 
ficult." 

In Banking's Abstract {loc. cit., p. 50) may be found the following 
statements in regard to the treatment by gymnastic exercises: 

They were first employed under the guidance of M. Laisne, gymnas- 
tic professor of the Polj^technic School, their effects being tried first on 
scrofulous children. " Commencing with simple movements of the legs 
and arms, accompanied by appropriate- songs, the cliildren's progress 
was so rapid that they were soon able to employ the orthopoedic ladder, 
the parallel bars, and other machinery, in succession. By the twenti- 
eth lesson they were exercised in wrestling, and afterwards in running, 
special exercises being devised for the lame. From the first lesson the 
children became fired with emulation, and movements which seemed 
impossible were soon executed with ease and pleasure. A marked 
amelioration was speedily observed, their countenances becoming ani- 
mated, their flesh firm, their voices stronger, their appetite keener and 
more regular; glandular swellings, which had long resisted all treat- 
ment, were resolved, and fistulous sores, that had been open for years, 
closed up. The lessons, one hour each, were given three times a week; 
and in the intervals the children amused themselves by repeating such 
of them as did not require machinery." This treatment, at first ap- 
plied to scrofulous children, was, as stated above, extended to those 
laboring under nervous affections, partial paralysis, rickets, and especi- 
ally chorea. Since 1847, ninety-five children suffering from chorea, 
sometimes so obstinate as to have resisted the most various treatment, 
have been cured by this means alone, or in conjunction with others, and 
no accident has resulted from the employment of the exercises. The 
movements are graduated according to the severity of the case, and 
they are repeated daily, but not for more than from fifteen to twenty- 
five minutes, so as not to induce fatigue or palpitation. " Improvement 
is sometimes seen after the first lesson, and at latest after the fifth or 
sixth; so that at the end of a week we can judge whether the means 
are likely to prove efficacious, and if manifest improvement has not 
then taken place, it is doubtful whether the cure will be thus effected, 
or if it is, it will be so only after a long time. The worst as well as the 
slightest cases have reaped equal benefit, the cure in the favorable ones 
only requiring a mean of twenty-nine days, and old or relapsed chorea 
being more amenable than recent. Dr. See has found that when other 
remedies are conjoined with the gymnastics, the proportion of cures is 



ATROPHIC INFANTILE PARALYSIS. 615 

less, and the period of their attainment later; and he recommends no 
other adjunct to be employed than good diet." (Dr. See on Chorea, 
loc. cit., No. 16, p. 50.) 

Hygienic Treatment. — The management of the hygiene of the pa- 
tient is quite as important as any other part of the treatment. The 
diet should be arranged to suit the particular condition of the indi- 
vidual, and with a view to procure and maintain the most healthful 
possible state of the digestive apparatus. It should always be light 
and easily digestible, in order that neither the stomach nor bowels may 
be oppressed and deranged by the products of an imperfect digestion. 
When the stomach is weak and dj^speptic, the food ought to consist 
for some days chiefly of preparations of milk and bread, whilst in the 
meantime, a tonic remedy is administered internally, in order to invig- 
orate the power of that organ. As the digestive function becomes 
stronger, the child ought, as a general rule, to be put upon the kind of 
diet most likely to promote the general health and vigor of body. It 
ought to consist of bread, milk, plain wholesome meats, and simple 
vegetables. Coffee and tea, and all other nervous stimulants, had 
better be avoided. The meats ought to be mutfon, beef, or poultry. 
There are few vegetables, besides rice, potatoes, and tomatoes, which 
are suitable under the circumstances. All candies, preserves, unripe, 
coarse, or dried fruit, hot bread and cakes, except the very simplest, 
ought to be withheld. 

Of dress we need merely say that it must be suited to the season. 
Exercise, or at least, exposure to fresh air and insolation, are of the 
utmost consequence. When the disease is so violent as to prevent the 
child from walking, it ought to be taken to drive as often as possible. 
In cases which seem connected with a debilitated and anaemic condi- 
tion of the constitution, removal to the country, and particularly to the 
seaside, will often effect a cure with great rapidity. Whenever, indeed, 
a patient inhabiting a large city or town can be conveniently taken to 
the seaside in the summer, it ought to be done, for the change is useful 
not only at the time, but it lessens, also, by strengthening and invigor- 
ating the constitution for the future, the danger of a relapse. 



AETICLE XI. 

ATROPHIC INFANTILE PARALYSIS. 

Paralysis in the young child, though occasionally met with in most 
of the forms observed in the adult, most frequently presents itself in a 
form almost peculiar to childhood, characterized by total or partial loss 
of power over one or several groups of muscles, usually without impair- 
ment of sensation, and often followed by atrophy of the palsied muscles, 
and consequent deformities. 



616 ATROPHIC INFANTILE PARALYSIS. 

History and Synonyms. — Occasional allusions to infantile paralysis 
maj^ be met with in medical writings even as far back as the latter part 
of the last century, but of such a vague and indefinite nature that the 
full recognition and accurate description of this peculiar affection cannot 
be said to date further back than the writings of Kennedy and Heine, 
in 1836 and 1810 respectively. Since the publication of Heine's classi- 
cal memoir, however, a number of observers have studied the disease 
with much attention and success. We have subjoined a list of the 
principal writings upon this subject to which we have been able to 
obtain access.^ It will be observed that the vague and discordant 

^ Bibliography. — Underwood, Treatise on Diseases of Children, London, 1789. 

Kostan, Eech. sur le Ramoll. du Cerveau, 28rne ed., Paris, 1823, obs. L. 

Shaw, on Nature and Treatment of Distortions, London, 1823. 

Cazauvieilh, Arch, Gen. de Med., t. xiv, 1827, pp. 5 and 347; Eech. sur I'Agen- 
isie et la Paral. Congeniale. 

Badham, London Medical and Surgical Journal, 1835. 

Kennedy, Observations on Apoplexy and Paralysis of New-born Infants; Dublin 
Jour. Med. Scien., 1886; and Dublin Med. Press, 1841 ; and Dublin Quart. Jour, of 
Med., 1850, and Nov. 1861. 

Marshall Hall, Lect. on Nervous'System, London, 1836, p. 81. 

Heine, Beobach. i\. Lahmungszustande der untern Extremitaten und deren Be- 
handlung, Stuttgart, 1840; and Spinale Kinder Lahmung, Stuttgart. 1860, see Can- 
statt's Jahr., vol. iii, p. 70, 1860; and Med. Times and Gaz., London, 1868. 

Graves's Clinical Med., 1843, p. 409. 

Colmer, London Med. Gaz., April 21, 1843. 

McCormac, Lancet, May 27, 1848. 

E. Doherty, Dublin Med. Jour., vol. xxv, 1844, p. 82. 

West, Lect. on Dis. of Childhood, London, 1848. 

Eichard (de Nancy), Bull, de Ther , Fevr. 1849. p. 120. 

Fliess, Jour. f. Kinderkr., July and August, 1849. 

Bellingham, Dublin Med. Press, 1850. 

Eilliet, Gaz. Med. de Paris, Nov. 1851. 

W. Gull, on Paralysis during Dentition, in article on Value of Electricity as a 
Eemedial Agent, Guy's Hosp. Eep., 2d ser., vol. viii, pt. i, 1852, p. 81. 

Little, on Deformities of Human Frame, London, 1858, p. 120. 

Eilliet and Barthez, Traite des Mai. des Enfants, ed. 2eme, 1854, t. ii, p. 545. 

Vogt, Essential Paralysis of Children, Berne, 1858, pp. 86; New York Journal of 
Med., Jan. 1859, p. 117. 

Eulenberg, on Essential Paralysis of Children, Virch. Arch., 1859, 177; and 
Schmidt's Jahrb., vol. 107, p. 55. 

Bierbaum, Paral3'sis of Children, Jour. f. Kind., 1859, 1 and 2, p. 18. 

Copland, Diet, of Pract. Med., vol. iii, Amer. ed., 1859, p. 24. 

Valleix, Guide du Medicin Pract., ed. 4eme, 1860, t. i, p. 759. 

Brunniche, u. d. sogennant. Essentiellen Lahmungen bei Kleinen Kindern., Jour, 
f. Kind., 1861. 

Echeverria, Atrophic Fatty Palsy in Infancy, Amer. Med. Times, July 18, 1861. 

Chassaignac, a Peculiar Form of Infantile Paralvsis, Med. Times and Gaz., Nov. 
9, 1861. 

Duchenne, De I'Electrisation Localisee, Paris, 1861, p. 275. 

Smith, Paraplegia occurring in Young Children, induced by Wet and Cold, Lan- 
cet, 1861. 

Bouchut, des Maladies des Nouveaux-nes, &c., ed. 4eme, Paris, 1862, p. 122. 

Cornil, Comp. Eend. de la Soc. de Biologic, 1868, p. 187. 



CAUSES. 617 

views which have been held in regard to its cause and nature, have 
led to the employment of many names by which to designate it. Thus 
it has been called by Heine infantile spinal paral^^sis, and Mej^er fol- 
lows him in the use of this terra; by Gull it was called paralysis 
during dentition ; by Rilliet and Barthez, Yogt, Eulenberg, Yalleix, 
Brnnniche, Laborde, and Xiemeyer, essential paralysis of children ; by 
Duchenne, who is followed by Echeverria, fatty atrophic paralysis of 
infancy; by Eeynolds, paralysis with wasting of the muscles; b}^ Bou- 
chut, myogenic paralysis; by Hammond, organic infantile paralysis; 
and it has also been called idiopathic and congestive infantile paralysis. 

AYe have been led to select the name which heads this article, be- 
cause those above enumerated appear to us to be either vague and in- 
accurate, as the terms essential and idiopathic; or to neglect one of the 
most striking features of the disease, the muscular atrophy, as the term 
infantile spinal paralysis does; or to convey a partial or even erroneous 
theory of the pathology of the disease, as the names congestive and 
myogenic respectively do. The terms organic and fatty atrophic pa- 
ralysis also seem to us defective, since the first is equally applicable to 
cases of palsy due to organic disease of the brain, while the second is 
based upon the fatty degeneration of the affected muscles, which, how- 
ever, occurs only in a portion of the cases of infantile paralysis. 

Causes. — The etiology of this affection is very obscure, doubtless 
partly owing to the fact that, as the paralysis occurs when the spinal 
system is extremely impressible, the causes which induce it are trivial 

Laborde, De la Paralysie (dite Essentielle) de I'Enfance, These de Paris, 1864. 

Jaccoud, Des Paraplegies, &c., Paris, 1864, p. 448. 

W. A. Hammond, on Organic Infantile Paralysis, New York Med. Jour., Dec. 
1865, p. 168; and Jour, of Psych. Med., vol. i, 1867, p. 49, and vol. ii, 1868, p. 531. 

Adams, on Club-Foot, London, 1866. 

Prevost, Comp. Kend. de la Soc. de Biologic, 1866, p. 215. 

C Handfield Jones, Functional Nervous Dis. (Amer. ed.), Philada., 1867, p. 88. 

J. Eussell Eeynolds, Lancet, vol. ii, July 11, 1868, p. 35. 

C. B. Eadcliffe, Art. on Infantile Paralysis, Eeynolds's Syst. of Med., vol. ii, 1868, 
p. 661. 

T. Hillier, Diseases of Children (Amer. ed.), Philada., 1868, p. 255. 

S. Wilks, Lect. on Nerv. Dis., Med. Times and Gaz., Dec. 19, 1868, p. 689. 

Z. Johnson and J. Lockhart Clarke, Med. Chir. Trans., vol. Ii, 1868. 

Moritz Meyer, Electricity in Practical Medicine (translated by W. A. Hammond, 
M.D.), New York, 1869, p. 218. 

Niemeyer, Practical Medicine (Amer. ed.). New York, 1869, vol. ii, p. 338. 

Yogel, Diseases of Children (Amer. ed.), New York, 1870, p. 391. 

Charcot and Joffroy, Cas de Paralysie infantile spinale avec lesions des cornes an- 
terieures de la substance grise de la Moelle epiniere, Arch, de Phys. Nom. et Path., 

1870, vol. ill, p. 134. 

. Parrot and Joffroy [id. loc.)^ p. 309. 

Vulpian (id. loc), p. 316. 

Allbutt, T. Clifford, London Lancet, November 10th, 1870, p. 481. 

Damaschino and Eoger, Gaz. Med., 1871, p. 457, and in Syd. Soc. Biennial Eetro- 
spect, 1871-72, p. 96. 

Einecker, Berlin Klin. Woch., 1871, p. 627. 

Eosenthal, Centralblatt, 1872, p. 176, from Oestr. Zeitschr. f. prakt. Heilkundl, 

1871, No. 52. 



618 ATROPHIC INFANTILE PARALYSIS. 

and usually entirely overlooked. Ago is the only influence which can 
be said to have a positive action in its production, since the great ma- 
jority of cases occur between the ages of six months and two years, 
during the period of primary dentition. By several of the early ob- 
servers especially, the disease was on this account attributed solely to 
dental irritation, but more careful observation shows that in most 
cases no such direct connection can be traced; and it is probable that 
early age and dentition only act indirectly by inducing a remarkably 
susceptible condition of the entire spinal s^^stom. 

Sex appears to have no influence whatever upon its production ; and 
the disease is almost as frequent among the children of the wealthy as 
among the ill-fed and ill-tended children of the poor. In some few 
cases, where the loss of power is sudden, the exciting cause seems to 
be the direct exposure to the local action of cold, as from sitting upon 
a stone step (West). 

Atrophic infantile paralysis is usually primary, and occurs in the 
midst of good health ; but it has also been observed in a secondary form, 
appearing during the convalescence from measles, scarlatina, or typhoid 
fever, or during rheumatism and chorea. 

In one of the cases following chorea, which are recorded by Kennedy 
(loc. cit.), it is positively stated that there was a distinct cardiac mur- 
mur, due to organic valvular disease; and it may be suggested that the 
essential cause of the paralysis was embolism of some of the spinal ar- 
teries, as observed by Panum.^ 

Mode of Attack; Initiatory Symptoms. — There is considerable va- 
riety in the mode in which this disease makes its appearance. In 
some cases the paralysis is the first symptom observed, and is found to 
have almost immediately attained its full extent, without any recog- 
nizable cause or premonitory S3nnptom. Thus the child may have ap- 
peared perfectly well when put to bed in the evening, and yet on the 
following morning, there may be more or less complete loss of power 
over the lower extremities. But in the great majority of cases, espe- 
cially the more severe ones, the attack is preceded by quite marked 
constitutional disturbance. This may consist merel}^ of fever, appear- 
ing without evident cause and lasting from a few hours to a week or 
more, unattended by any gastro-intestinal disturbance. Or, during 
this period, the child may also complain of pain in the back, or there 
may be tenderness on pressure, especially in the lumbar region ; there 
is frequently slight dulness of the mind, or finally, in comparatively 
rare cases, one or more convulsion may occur. It is the rule, however, 
for no marked symptoms of cerebral disturbance to be present at any 
period of the disease. There are rarely any symptoms connected with 
the parts about to become paralyzed, though in an interesting case re- 
corded by Kennedy (loc. cit.), there was spasm of the muscles subse- 
quently affected. 



1 Ueber den Tod durch Embolie (Bibhothek fur Liiger, 1856), quoted by Jaccoud 
(op. cit., p. 297), and Arch. f. Path. Anat. xxv, 308, 443, 1863, in Year-book of N". 
Syd. Soc. 1863, p. 210. 



MUSCLES AFFECTED — SYMPTOMS. 619 

The disease usually makes its appearance during health, but it is 
probable that many of the cases of paralysis occurring during con- 
valescence from the various exanthemata properly belong to this va- 
riety. 

Whether preceded by initiatory symptoms or not, the development 
of the paralysis is generall}^ sudden, and it is only in rare cases that it 
is partial at first and increases gradually. Indeed it usually happens 
that Avhen first observed the paralysis is at its maximum, both as re- 
gards the number of muscles affected and the degree of the loss of 
power, and that there soon occurs a diminution in its extent, so that 
only some of the parts first affected remain palsied. 

The form of the paralysis clearly indicates its spinal origin. Com- 
plete hemiplegia is scarcely ever observed, though in a few cases the 
arm and leg of the same side, or even all four extremities, have been 
palsied.^ Most frequently the disease takes the form of incomplete 
paraplegia; though occasionally the paralysis affects single groups of 
muscles or even individual muscles. 

According to Mr. Adams, the groups of muscles most frequently 
affected are: 1. The muscles of the anterior parts of the leg, forming 
the extensors of the toes and the flexors of the foot; 2. The extensors 
and supinators of the hand, these muscles being always affected to- 
gether; and 3. The extensors of the leg, and with them generally the 
muscles of the foot, as in the first group. When single muscles are 
affected, the most likely to suffer are these : 1. The extensor longus 
digitorum of the toes ; 2. The tibialis anticus ; 3. The deltoid ; and 4. 
The sterno-mastoid. 

The bladder and rectum are very rarely involved. 

The degree of the paralysis varies as much as its extent; usually com- 
plete at first, in some cases it soon becomes partial or even slight ; while 
in others the loss of power remains absolutely complete. The paralyzed 
muscles are perfectly relaxed, so that the affected parts can have all 
their normal movements impressed upon them without difficulty, and 
fall in a lifeless manner if left unsupported. The special senses are un- 
impaired; and general sensibility is usually only blunted for a time. 
Occasionally it is not affected at all, or, as stated by West, there may 
even be hyperesthesia for a variable time. 

1 With reference to the parts aifected, in 43 cases observed and analyzed by West, 
in only 2 was the arm alone palsied, though in 19 instances the paralysis was limited 
to one or both legs. In 8 cases the right leg, and in 5 the left, was paralyzed ; and 
in one of the former instances paralysis of the right portio dura was also present. In 
6 instances, the right arm and leg, and in 8 the left arm and leg, were affected, with 
which ptosis of the left eyelid was once associated, and once paralysis of the left portio 
dura. Paraplegia existed in 8 instances, combined in one case with paralysis of the 
right arm, and in another with loss of power over both deltoid muscles, and over the 
flexor muscles of both thumbs. Six times none of the limbs were palsied, but the af- 
fection was confined once to the portio dura of the left, and five times to the portio 
dura of the right side ; but in one of these instances, though there was no actual pa- 
ralysis, the patient's gait was feeble and tottering. 



620 ATROPHIC INFANTILE PARALYSIS. 

The paralj-zed muscles are rarely the seat either of painful subjective 
sensations or of tenderness on pressure ; though in some cases severe 
pain may be present in the affected parts. 

Ecflex movements are, as a rule, abolished in those parts Avhere there 
is complete loss of voluntary motion ; though Laborde (loc. cit.~) has 
shown that they may occasionally be j^reserved even in the first stage 
of the paralysis. 

During the early stage we are at present considering, the electro- 
muscular contractility usually remains intact, and the muscles respond 
both to the induced and direct current. 

The constitutional disturbances which we have described as preceding 
the paralysis, may persist for a variable time after its development, or 
disappear quickly, leaving no other s^niiptoms present but those con- 
nected with the paralyzed parts. 

The following case, seen by one of ourselves w^th Dr. James Tyson, 
may be quoted as an illustration of this form of paralysis. 

A ina.le child, set. thirteen months, was brought to Dr. Tyson for treatment by its 
mother, an intelligent woman, with several healthy children. The following history 
of the case was obtained : The little boy had walked at the age of nine months, and 
always seemed a vigorous, intelligent child; he had also cut eight teeth, without 
much irritation. About Sept. 10th, 1868, after no particular exposure, he became 
fretful and feverish, with occasional vomiting ; and after three days it was noticed 
that right-sided hemiplegia had developed itself. The paralysis of the arm was never 
complete, while the leg had entirely lost all power of motion. This loss of power 
had not become complete suddenly, but, at lirst partial, had gradually increased. 
There was no tendency to coma and no evidence of any acute pain. The febrile 
symptoms soon disappeared ; the arm regained the power of motion in a few days, 
but the leg remained palsied. It also soon grew remarkabh^ cold, and when seen on 
October 1st, three weeks after the attack, the temperature was decidedly lower than 
that of its fellow. Sensation was impaired, but had never been abolished. There 
had been no paralysis of either bladder or rectum. At the time of the examination, 
the child seemed bright and lively, though rather pale. There was no tenderness 
along the spine, nor in the \eg. No reflex movements were developed in the par- 
alyzed leg by tickling the sole of the foot. Neither atrophy nor deformity had as yet 
occurred. 

The subsequent course of the disease varies greatly in different in- 
stances. In one set of cases, though the paralysis may be quite exten- 
sive and complete at first, the symptoms gradually subside, the paralysis 
disappears, and complete recovery ensues in from four to six weeks. 
These cases correspond exactly to the form of paralysis originally de- 
scribed by Kennedy Qoc. cit.) under the name of " Temporary Infan- 
tile Paralysis," and, as we shall see hereafter, in all probability depend 
upon mere congestion of the spinal cord. 

In the other set of cases, on the contrary, the loss of power persists, 
and after it has continued for a time, varying from one to several 
Dionths, is followed by marked and more or less rapid atrophy of the 
affected muscles. The circulation in the paralyzed parts becomes 
feeble, the subcutaneous veins are smaller, and Heine, and Eilliet and 
Barthez each cite a case of paralysis of the arm in which it was al- 



ATROPHY AND DEFORMITY. 621 

most impossible to detect the radial pulse. The temperature of the 
aftected part becomes perceptibly lower, the fall amounting, according 
to Hammond, to from 5 to 8 or even 10 degrees, as tested by a galvan- 
ometer. The muscles themselves undergo marked atrophy", frequently 
accompanied by fatty degeneration; and their reflex motility and elec- 
tro-muscular contractility disappear. It is important to notice, how- 
ever, that long after muscular contractions fail to be produced by the 
induced current, they may frequently be excited by the use of a direct 
current of low tension, slowly interrupted. 

The mere wasting of the muscles is not, however, the only cause of 
the great difference in size between the healthy and paralyzed members. 
The nutrition of the whole limb is affected, and the growth and devel- 
opment of all its tissues arrested, so that the paralyzed member be- 
comes smaller in all its dimensions than its fellow. Eilliet and Barthez 
cite an example which they observed; to show to how remarkable a 
degree this conjoined atrophy and arrest of development may progress. 
The patient was a young girl who was seized with instantaneous pa- 
ralysis of the right lower extremity; and the following measurements 
show the degree of inequality which was produced by four years' con- 
tinuance of the paralysis and arrest of development: 

Right leg. Left leg. 

1. From the great trochanter to the external malleohis, 49 cent. . 54 cent. 5 mill. 

2. From the patella to the malleolus, . . . 29 " . 32 " 

3. Length of foot from heel to great toe, . . . 14 " 3 mill. 18 " 

Five months previously, the following diminution in thickness of the 
limbs was noticed: at three fingers' breadth above the patella, on left 
side, 20 centimetres, 16 on right: at the middle of the thigh, on left 
side, 29 centimetres, and 22 on right. The height of the child was 
116 centimetres. 

This wasting and palsy of the muscles is associated with relaxation 
of the ligaments, and the combination of these causes induces many of 
the deformities observed in childhood. When the paralysis affects one 
side of the body chiefly, it indirectly leads to various lateral curvatures 
in the spinal column, probably from a want of symmetrical action in 
the muscle.-- of the two sides. 

In cases of paralysis of the arms, the relaxation of the ligaments 
about the shoulder-joint and the atrophy of the deltoid allow the head 
of the humerus to drop out of the glenoid cavity, so as to produce even 
complete dislocation, with apparent elongation of the paralyzed limb 
to the extent of three-fourths of an inch (West). 

As the muscles of the lower extremities are far most frequently 
affected in this form of paralysis^ we usually find the resulting deformi- 
ties involving the feet and legs, where they constitute the greater pro- 
portion of all cases of club-foot. According to Adams {loc. cit.), "these 
deformities occur in the following order of frequency : 1. Talipes equinus; 
2, equino-varus; 3, equino-valgus; 4, calcaneus, or calcaneo-valgus; and 



622 ATROPHIC INFANTILE PARALYSIS. 

5, talipes varus. When both feet are affected, eqnino-varus of one foot 
is fi^enerally found with eqiiino-valgus of the other." 

In addition to the influence which the actual wasting of the limb and 
the arrest of its development exert, Adams believes that the great cause 
of such deformities is the -'adapted atrophy " of Paget, the changes which 
ensue in consequence of the mechanical relations of the foot to the leg. 
Although, however, it is true that paralysis of a group of muscles does 
not excite active contraction in their opponents, it appears that in the 
efforts of the child to move the part, the non-paralyzed muscles must 
gain control over the limb, and aid at least in producing the various 
characteristic distortions. 

During the development of this atrophic stage, the general sensi- 
bility of the affected parts is usually normal, and the general health, 
intelligence, and nutrition of the patient unimpaired. 

Duration. — As will be inferred from our description of the course of 
this affection, the entire duration and that of its different stages varies 
greatl}^ in different cases. In some, which have hence had the name 
"temporary" infantile paralysis bestowed upon them, the loss of power 
rapidly diminishes, and complete recovery follows in from a few days 
to a few weeks; while, in other cases, the paralysis persists until 
atrophy ensues, and the limb may remain crippled and useless through- 
out life. The period which elapses before atrophy commences, and the 
rapidity with which it advances, also vary extremely, even in appar- 
ently similar cases. Thus the palsied muscles may begin to atrophy 
within four or five weeks, though more frequently this change cannot 
be noticed for several months. Different muscles also atrophy with 
very different rapidity, the deltoid and tibialis anticus appearing to 
waste more rapidly than any other muscles of the body; and, in dif- 
ferent cases, the same groups of muscles show equal variety in this 
respect, a few weeks serving in some instances for as much wasting to 
occur as would require months to produce in other cases. 

Prognosis. — The great uncertainty of the progress and duration of 
atrophic infantile paralysis render it highly desirable to ascertain, if 
possible, the conditions which determine its result. Of itself, it is never 
fatal; but, unfortunately, our prognosis is limited, in the early stage of 
the disease, to this assertion, for the duration and course of the case 
are not influenced, in any constant and reliable way, either by the age 
of the patient, the extent of the paralysis or the parts affected, or the 
initiatory symptoms. It may perhaps be stated that, in general, cases 
which are ushered in by high fever, esj)ecially if associated with con- 
vulsions, and in which the paralysis is extensive, will prove severe and 
tedious. But there are too many exceptions to every particular of this 
statement for it to be regarded as a general rule of much positive value 
in prognosis. 

When paralysis has lasted three or four weeks, we are able to deter- 
mine with much accuracy the approach of atrophy by the condition of 
the electro-muscular contractility; for it has been frequently observed 



MORBID ANATOMY AND PATHOLOGY. 623 

that those muscles which lose their power of responding to the inter- 
rupted current, soon begin to waste. 

After the occurrence of atrophy, also, much valuable aid in prognosis 
is gained from the use of electricity. 

\ye may here mention the interesting and highly important obser- 
vation, first made in connection with this disease by Hammond {loc. 
cit.) and J. ]Netten Eadcliffo,^ that in many cases where die atrophied 
muscles have lost entirely their power of reacting to the most powerful 
induced electrical currents, they will still react vigorously to a direct 
(galvanic) current of low tension and slowly interrupted. The im- 
portance of this discoveiy, in the treatment of the disease, can scarcely 
be overrated; and it has also enabled this point to be established in the 
prognosis, that whenever muscular contractions can be excited by either 
induced or direct currents, no matter how far advanced the atrophy of 
the muscles, the restoration of their power can certainl}^ be accom- 
plished; though it would appear from a case successfully treated by 
Hammond, that even when such contractions are not at first pro- 
duced, the prognosis is not absolutely unfavorable. The still more 
curious, and as yet inexplicable observation has also been frequently 
made, that as the muscles regain their power of voluntary motion, 
their susceptibilit}' to the direct galvanic current is apt to diminish, 
but, on the other hand, their normal reaction to the induced current 
returns. 

The prognosis will also be materially influenced, especially when the 
atrophic stage has begun, b}^ the condition in which the tissue of the 
palsied muscles is found, as in cases where advanced fatty degeneration 
is present, it is far more unlikely that they will ever regain their power. 
In order to ascertain this point, Duchenne has devised a small trocar,^ 
called by him " emporte-j^iece," by which small pieces of muscle can 
be extracted, and subsequently submitted to microscopic examination. 

It is evident, finally^ that the dui-ation and result will depend, to a 
great extent, upon the period at which treatment is instituted. In those 
cases where the paral^'sis has been allowed to continue until marked 
atJ'ophy has ensued, and the electro-muscular contractility is almost 
lost, although the prognosis may still be fiivorable as regards the ulti- 
mate cure, it must be carefull}' guarded as to the duration, since the 
treatment will probably require to be steadily pursued for many weeks, 
or even months. 

Morbid Anatomy and Pathology. — It appears desirable to introduce 
the consideration of the anatomical appearances at this point, in order 
to facilitate the subsequent discussion of the pathology and diagnosis of 
the disease. 

In regard to the changes which take place in the atrophied muscles, 

^ See foot-note to pa<j;c 6(Jo, vol. ii, Reynolds's SN'stem of Medicine. 

2 The!«e trocars are manufactured by Tiemann, of New York. Dr. Hammond 
has published (Jour, of P^ych. Med., July, 18G7) a description of their form and 
mode of use, illustrated by a woodcut. 



624 ATROPHIC INFANTILE PARALYSIS. 

the brief jet complete summary given by Hillier, may be quoted (op. 
ciL, page 268) : 

" 1. The transverse strias become less apparent and separated by 
wider spaces, which are filled with opaque granules, which are not 
dissolved by ether, but are sensiblj^ acted on by acetic acid. 

" 2. The transverse striae disappear, and there is an abundant appear- 
ance of e;ranular substance. 

"3. There remain but slight traces of longitudinal fibres, filled with 
granules, with a larger quantity of connective tissue between the bundles. 

"4. The granules have disappeared, and empty transparent tubes of 
myolemma with a few scantj^ granules on their walls remain, with more 
connective tissue and some elastic fibres. 

"5. In some cases, fat-globules take the place of the granular matter 
in the muscular fibres, and in the cellular tissue between the bundles of 
muscular fibre. This change is not universally present in cases even 
when atrophy has proceeded to an extreme degree." 

The last conclusion stated here, which has been confirmed b}^ other 
observers, shows that perhaps the most frequent change which occurs, 
is a simple atrophy of the muscles, with a granular but non-fatty de- 
generation, and conclusively shows the inaccuracy of the name proposed 
by Ducheune for the disease (namely, fatty atrophic paralysis of infants). 

In approaching the question of the lesions of the nervous centres in 
this affection, it is necessary to refer to the general question of the ex- 
istence of so-called essential, purely neurotic paralyses. In one form 
of paralysis, the reflex, it is true that as yet no material lesion has 
been detected, and that the most plausible explanation of the loss of 
power in such cases is simply the exhaustion of the functional activity 
of the spinal cord, owing to the prolonged irritation of some of the pe- 
ripheral nerves. And it must be borne in mind that by some the form 
of infantile paralysis under consideration has been regarded as a reflex 
paralysis depending on dental irritation. Apart, however, from the 
fact, that the symptoms much more closely resemble those due to spinal 
congestion than those seen in reflex paralysis, it is to be remembered 
that the disease is by no means limited to the period of dentition, and 
that all local signs of dental irritation are frequently absent at the time 
of the appearance of the paralysis. With the exception, then, of reflex 
paralysis, it may be asserted with confidence that all other forms of 
spinal paralysis are associated with some material lesion of this nervous 
trunk. It is to be remembered that it is only a few years since the 
beautiful researches of J. Lockhart Clarke have shown that positive 
structural changes, in both nerve-cells and nerve-fibrils, may be detected 
hy microscopic examination in spinal cords, which present no altera- 
tion apparent to the naked eye. In rejecting the evidence of all post- 
mortem examinations of the spinal cord, made before the introduction 
of Clarke's method, as incomplete and inconclusive, we find that in all 
those diseases formerly classed as pure neuroses (such as tetanus and 
chorea), which have been subjected to this latter mode of examination, 
positive demonstrable lesions have at least occasionally been detected. 



MORBID ANATOMY AND PATHOLOGY. 625 

Among this class of diseases, so long considered as purely functional 
neuroses, atrophic infantile paralysis has always, until latel}', occupied 
a prominent position, as is evinced by the large number of authors who 
have described it under the terras "essential," or "idiopathic." 

It is indeed difficult to secure opportunities of examining the state of 
the spinal cord in this affection, owing to the fact that the disease is 
scarcely ever, if at all, fatal of itself; so that the arguments in opposi- 
tion to the view of its functional nature, will be in part drawn from 
the close analogy of its S3'mptoms to those of certain spinal diseases, 
which are well known to be attended with positive lesions of the ner- 
vous tissue. Thus, in its mode of appearance, and in the character of 
the paralysis, there is so perfect a resemblance to the onset and symp- 
toms of congestion of the spinal cord, as to leave little room for doubt 
that this is the condition at first present in many cases of atrophic in- 
fantile paralysis. In both this affection and spinal congestion, the pa- 
ralysis may appear quite abruptly, or be preceded by pains in the back 
and fever; in both, the paralysis is usually paraplegic, the loss of power 
only partial, and the affected muscles are relaxed; in both, general sen- 
sibilit}' is but slightly impaired, the bladder and rectum are not involved, 
and there are no disturbances of the cerebrum or special senses; in both, 
finall}', recovery usually follows, if proper treatment be promptly in- 
stituted. 

In those cases where the paralysis disappears within a few days or 
weeks, it has been supposed by various authors that the nature of the 
disease is entirely different from that of atrophic infantile paralysis ; 
but it appears to us highlj^ unnecessary to complicate the question by 
such a supposition, since the temporary character of the paralj'sis is 
readily accounted for by supposing that the spinal congestion which 
produced it w^as slight and transient. 

It is quite possible also that in other cases the loss of power caused 
by more severe spinal congestion should persist until atrophy of the 
affected muscles ensued, and rendered the case more protracted. 

Indeed, some of the authors who most forcibly support the view of 
the pathology of this affection which we have given above, as Dr. C. B. 
Eadcliffe (loc. cit.), hold that the lesion of the cord does not advance 
beyond this stage of congestion. The evidence in support of this 
opinion is principally found in the result of post-mortem examinations, 
as those reported by Eilliet and Barthez, Fliess and Adams, where no 
lesions of the cord were detected. But in none of these' cases does it 
appear that the careful and skilful microscopic examination, which is 
now recognized as necessary to detect some lesions of the nervous 
tissue, was performed; so that we may feel at liberty to doubt the 
complete accuracy of these autopsies. On the other hand, it certainly 
seems entirely consistent to suppose that in certain cases, where the 
congestion is unusually marked and prolonged, or where it is repeated, 
that a process of subacute inflammation should be excited, resulting in 
the permanent structural change. 

The usual change which takes place in the spinal cord, under such 

40 



626 ATROPHIC INFANTILE PARALYSIS. 

circumstances, is that described uuder the name " sclerosis," in which 
there is marked proliferation of the connective-tissue elements of the 
cord, with swelling and consequent pressure upon the nerve-tubules. 
In the subsequent development of the new-formed connective tissue, it 
undergoes contraction, and induces atrophy of the compressed nerve- 
tubules. The portions of the spinal cord where this lesion exists, may 
either be atrophied or retain their normal size, shape, and external ap- 
pearance, but on transverse section, though the tissue is firm, certain 
parts of the w^hite substance arc seen to present a grayish, translucent 
appearance, differing noticeably, in well-marked cases of the lesion, 
from the opaque whiteness of the surrounding healthy tissue. In 
other instances, however, the change in color cannot be detected, and 
it is only by microscopic examination that we can discover the increase 
in the connective tissue of the cord, and the atrophy of the nerve- 
tubules. 

This view of the nature of the lesions in atrophic infantile paralysis, 
was forcibly urged by Heine, in the last edition of his classical mono- 
graph on this subject {op. cit.), who based it merely upon an analysis of 
the sj-mptoms, and it has since been adopted by Jaccoud fjoc. cit.). It 
does not rest, however, solely upon such reasoning, for there have been 
a limited but rapidly increasing number of autopsies made in which 
the above-described lesions of sclerosis have been actually observed. 

Heine quotes three post-mortem examinations in support of this 
theory. One of these, quoted from Longet, was of a girl of eight years, 
with club-foot on the right side, following an attack of paral^-sis, who 
died of variola; and at the autopsy the muscles and nerves of the right 
leg were atrophied, and the anterior roots of the spinal nerves which 
make up the right sciatic nerve, were scarcely one-quarter the size of 
the corresponding roots on the left side. 

In the second case, quoted from Hutin, the subject was forty-five 
years old, had been paraplegic from the age of seven years, and had 
considerable deformity of the lower members; at the autopsy, after 
death from dysentery, there was atrophy of the lower ]Dart of the spinal 
cord. 

The third observation quoted by Heine, has been quoted more fully 
from the original source {Trans, de la Soc. Med. de JBerlin, Dec. 7th, 
1862), b}^ Jaccoud (op. cit., p. 450). It was the autopsy of a child with 
paralytic club-foot, reported by Berend and Eemak, where the "spinal 
arachnoid was found thickened by inflammatory product, and exer- 
cising such pressure upon the cord, that when the false membranes 
were cut, the nervous tissue immediately protruded through the in- 
cision." 

Berend also reported (id. loc.) another observation upon a child four 
years old, who died paraplegic with contraction of the legs and feet. 
The autopsy was performed by Recklinghausen, who found tubercles 
in the cord. 

Hammond reports (Jour, of Psych, lied., vol. i, p. 51) a case where 
the paralysis affected the left leg, and had lasted four years, in which 



MORBID ANATOMY AND PATHOLOGY. 627 

he found, upon post-mortem examination, a cicatrix, partly filled with 
clot, in the lower part of the dorsal region, in the left anterior column. 
Eecently. however, the opportunities for careful study of the lesions in 
atrophic infantile paralysis have multiplied, and have been seized by 
numerous able observers, especially in Finance, where the first demon- 
stration of the true characteristic morbid changes in this disease was 
eflfected. The earliest cases placed upon record in which this lesion 
was accurately described were b}^ Cornil (loc.cit.) in 1863; by Laborde 
(loc. cit.^, in 1864 ; b}^ Prevost (loc. cit.), in 1866 ; J. Lockhart Clarke 
{loc. cif.), in 1868; Charcot and Joffroy {loc. cit.), in 1870; and numer- 
ous other observers have followed in confirmation, so that the morbid 
anatomy of atrophic infantile palsy may be regarded as clearly and 
fully determined. 

The lesions occupy the antero-lateral columns, and especially the 
anterior horns of gray matter. There is atrophy of the nerve-fibres in 
the anterior and lateral columns, which varies in amount in different 
cases, and is associated with a varying degree of hypertrophy of the 
interstitial connective tissue (sclerotic). These parts are more trans- 
lucent than natural, and often present a verj^ appreciable grayish rose 
tint to the naked eye. The consistence of the affected tracts is dimin- 
ished, and upon microscopical examination there may be observed a 
marked proliferation of the elements of the connective tissue, the cells 
and nuclei being dispersed in the midst of a finely granular substance, 
in which there are fibrils of extreme tenuity. In the parts which are 
most affected the nervous tubules are either lost altogether, or they 
present a varicose appearance, while the other portions of the spinal 
column preserve a perfect integrity. 

But the most characteristic changes are found in the anterior horns 
of gray matter, where there is invariably atrophy of the ganglion 
nerve-cells and of their processes, so that in some instances the anterior 
group of cells has entirely disappeared from atrophy. In other cases 
the remain^ of the cells are found atrophied, misshapen, and with gran- 
ular degeneration of their contents. The other elements of the gray 
tissue are usually changed also; there is proliferation of the nuclei of 
the neuroglia, and occasionally increase in the delicate fibrils of this 
connective tissue. In some cases the walls of the vessels in the affected 
parts are found thickened, with proliferation of their nuclei. These 
changes have been so prominent in some cases as to have led to the 
opinion (Damaschino, Duchenne) that they constituted the primary 
and essential lesion. This, however, does not seem probable. 

It is thus seen that the progress of anatomical investigation has at 
last developed the true pathology of this affection. It is possible that 
in some cases the lesion of the antero-lateral columns may be the re- 
sult of hemorrhage into the substance of the cord, or of pressure from 
thickening of the meninges; but in the vast majority of cases the mor- 
bid process is one of slow subacute inflammatory, sclerotic change, 
with atrophy of the nerve-tubules in the antero-lateral columns and 
anterior horns of gray matter, and especially with atrophy and destruc- 
tion of the anterior groups of ganglion nerve-cells. 



6*28 ATROPHIC INFANTILE PARALYSIS. 

Diagnosis. — There is but little danger of overlooking the nature of 
those cases where the paralysis appears quite suddenly in the midst of 
apparent good health, excepting in cases occurring in young children 
who have not yet learned to walk, and where the loss of power is lim- 
ited to the lower extremities. In such instances the paralysis may be 
entirelj^ overlooked by the parents or nurse for some time. So also in 
eases preceded by constitutional disturbance, as there is nothing what- 
ever characteristic in these premonitorj^ symptoms, it is quite possible 
to fail to recognize the presence of paralysis. It is well, therefore, 
whenever a child between six months and three years of age presents 
feverish symptoms for which no apparent cause exists, to ascertain 
carefully whether there is any loss of power of its extremities. 

The diseases with which atrophic infantile paralysis is most likely 
to be confounded, are other forms of paralysis of cerebral or spinal 
origin, and progressive muscular atrophy. 

In paralysis due to hemorrhage into the substance of the brain (see 
page 523), the case is more apt to be ushered in by delirium or convul- 
sions, followed by more or less marked coma, while in atrophic infan- 
tile paralysis there is either entire absence of cerebral symptoms, or at 
most a single convulsion occurs. Cerebral paralysis is usually hemi- 
plegic, while in the form of spinal paralysis we are considering, para- 
plegia is more common, or the loss of power may be limited to one leg 
or to a single group of muscles. In those comparatively rare cases 
where the paralysis is at first hemiplegic, the arm usually soon regains 
its power of motion, leaving the leg paral^^zed; while the reverse of 
this occurs in cerebral hemiplegia, where the leg usually improves 
much more rapidly than the arm. In cerebral paralysis, also, the af- 
fected muscles are frequently rigid instead of being relaxed; and there 
is not the tendency to atrophy and deformity, the loss of electro-mus- 
cular contractility, nor the lowering of the temperature of the affected 
part, which are observed in atrophic infantile paralysis. 

In cases of meningeal apoplexy where the hemorrhage has occurred 
upon the surface of the brain, the sj^mptoms are still more distinct. 
Thus (see page 524) there are usually repeated convulsive seizures, 
with somnolence during the intervals: paralysis is rare and partial, 
while strabismus and tonic contraction of the hands and feet are very 
common. 

In acute inflammation of the spinal cord, or myelitis, the loss of 
power is complete, and there is also more marked loss of sensation, and 
paralysis of the rectum and bladder, with alkaline urine; though there 
is here as well as in atrophic infantile paralysis, diminution of reflex 
excitability and electro-muscular contractility, and wasting of the para- 
lyzed muscles. The symptoms first mentioned, the more grave char- 
acter of the case, and the tendency of the paralysis to increase rather 
than decrease, suffice to distinguish myelitis from the affection under 
consideration. 

Progressive muscular atrophy, of very rare occurrence in children, 
may be distinguished by its gradually progressive course; and by the 



TREATMENT. 629 

preservation of the temperature of the affected parts, of the power of 
motion, and of electro-muscular contractility, until atrophy has far ad- 
vanced. There is usually a quivering of the atrophied muscles in this 
disease, due to fibrillar contraction, which is entirely wanting in atro- 
phic infantile paralysis. 

We have already expressed our belief that some of the cases where 
the loss of power is very temporary, are really instances of reflex pa- 
ralysis, and in such some source of peripheral irritation can usually be 
detected. 

West alludes to the fact that in those cases where the affection is 
limited to one leg, and attended by hypemesthesia and painful sensa- 
tions, the disease may be mistaken for coxalgia, though the diagnosis 
may readily be made by attending to the slow course, the absence of 
paralysis, the fixed pain in the knee-joint, and the marked increase of 
suffering caused by forcing the head of the femur against the acetabu- 
lum, which characterize hip-disease. 

Treatment. — The treatment of atrophic infantile paralysis may be 
divided into that adapted to the early stage and that directed against 
the second stage or period of atrophy. 

In the first instance we must endeavor to discover and remove any 
exciting cause of the paralysis that may exist. If symptoms of mor- 
bid dentition have preceded, and the appearance of the gums indicate 
it, they should be lanced; or if gastro-intestinal disturbance is present, 
or the presence of worms is suspected, laxatives should be administered. 
Tepid baths are also recommended, as tending to allay irritation and 
reduce feverishness. 

When, however, no local irritation can be detected to render it pos- 
sible that the case is one of reflex paralysis, we should direct our reme- 
dies towards relieving the spinal congestion, which we believe to exist 
in cases of true atrophic infantile paralysis. Counter-irritation should 
be applied along the spine, and may be effected by producing a narrow 
blister, or preferably by the use of sinapisms or stimulating liniments, 
containing croton oil, ammonia, or turpentine. 

Local abstraction of blood by means of cups or leeches applied along 
the spine has been recommended by Fliess; and we should certainly 
advise its employment, especially in those cases where there is consid- 
erable febrile disturbance and pain in the back. 

There are also certain remedies from which we have obtained excel- 
lent results in the treatment of spinal congestion in the adult, and 
should, therefore, recommend their employment in the early stage of 
this affection. 

These are ergot, which may be given in the form of fluid extract, 
beginning with doses of about 5 minims for a child of two years old ; 
and belladonna, which may be given either in the form of tincture, or 
an aqueous solution of the extract. Iodide of potassium may also be 
given in combination with one or the other of these, in doses of gr. j 
or ij for a child of two years old, in the hope of preventing the devel- 
opment of any inflammatory changes in the cord. 



630 ATROPHIC INFANTILE PARALYSIS. 

In addition to these remedial measures, the child should be abso- 
lutely confined to bed. 

If, despite the use of these agents, the paralysis persists, the tempe- 
rature begins to fall, and the muscles to atrophy, every means must be 
adopted to promote the general nutrition of the child so as to favor- 
ably influence indirectly the changes in the spinal cord; and, at the 
same time, local treatment must be instituted to promote the circula- 
tion and nutrition of the paralyzed parts. 

Among the internal remedies, iron is one of the most suitable, and 
may be given in 'dny eligible form. The pyrophosphate is perhaps 
especially indicated on account of the phosphoric acid with which the 
iron is combined. 

The various preparations of nux vomica or its alkaloid strychnia are 
also very valuable after the acute stage has passed. Heine advises the 
use of tr. nucis vomicae in combination with camphor and pyrethrum; 
while West recommends the alcoholic extract of nux vomica. Strychnia, 
which is more frequently employed than the preparations of nux vomica 
itself, is usually given in the form of solution. Hillier has also used it 
hypodermically, but without marked benefit. 

The doses of these powerful drugs, which are recommended by some 
authors, especially Heine, appear to us too large to be safely admin- 
istered. 

We should recommend beginning with a dose of at most gtt. ij of the 
tincture, or gr. ^V^^ of the alcoholic extract of nux vomica, or gr. -g^g^^ 
of sulphate of strychnia, for a child of two years old; the amount being 
increased steadily but cautiously so long as no unpleasant symptoms 
are produced by it. 

Local means must also be employed for inducing increased circulation 
in the affected parts. For this purpose, the stimulating liniments already 
mentioned, or moist heat, may be applied. Passive motion, and knead- 
ing the muscles, also aid in improving their nutrition and contractile 
power. 

Electricity, however, certainly ranks first among the local means for 
restoring the contractile power of the paralyzed muscles. It is true 
that several authorities have asserted that they derived no good results 
from its employment, but since the introduction of localized electricity 
(faradization), as developed by the researches of Duchenne, and of the 
use of the constant current, the most marked benefit has been obtained 
at all stages of this form of paralysis. 

If the induced current be used, it must be carefully isolated and 
limited to the affected muscles, by means of wet sponges fastened to 
the electrodes. In those cases where the muscles refuse to respond to 
an induced current even of considerable power, the direct current, slowly 
interrupted (the labile current of Eemak), will be found to induce con- 
tractions, excepting where the muscular tissue is far advanced in fatty 
degeneration. In all such cases then, this direct current should be 
employed. We have already alluded to the curious observation which 
has been made by several authors, that as the palsied muscles regain 



GYMNASTIC AND MECHANICAL TREATMENT. 631 

their power under the use of the direct current, they respond to it less 
and less strongly, while the indireed current is found to again have the 
power of exciting muscular contractions. When this period in the 
treatment of the case arrives, it is probably desirable to substitute the 
use of the induced current. 

In order that the use of electricity, in either form, may be productive 
of the excellent results it is capable of 3'ielding, it must be applied 
thoroughly to each of the paralyzed muscles three or four times weekly, 
and this treatment pursued for months, until the muscles regain both 
their size and contractile power.^ 

One of the earliest symptoms of improving nutrition is an elevation 
in the temperature of the part, which may readily be detected by the 
galvanometer, as before mentioned. The value of this mode of treat- 
ment is, indeed, so great "that so long as muscular contraction can be 
induced, recovery is merely a matter of time, but if no action of the 
paralyzed muscles can be brought about, the prognosis must be unfavor- 
able, though even here there is some hope." (Hammond, Eadcliffe.) 

In addition, however, to the local and general measures above recom- 
mended, there is another kind of treatment scarcely less important, 
which should be employed in conjunction with them. 

This consists in the use of such mechanical apparatus and gymnastic 
exercises as shall tend to bring the affected muscles into play, and to 
obviate the deformities of the atrophic period. The greater part of our 
knowledge upon this subject, is due to the admirable and extensive ob- 
servations of Heine, who has the superintendence of a large orthopaedic 
institute, and has most carefully studied the effects of these agents upon 
cases of paralj^sis which have progressed to the stage of atrophy and 
deformity. But it is b}" no means to this advanced stage alone that 
such measures are adapted, for it is a matter of the highest importance, 
that from a very early period of the paralysis, the little patients should 
be subjected to this treatment. 

If the legs be affected, it is not surprising that the child, who has, 
perhaps, gained but imperfect use of its limbs, and is making its first 
essays in walking when the paralysis appears, should feel such a sense 
of insecurity, even when the power of motion has returned to a con- 
siderable extent, that it will refuse to make any renewed efforts to walk. 
And the parents, finding all their attempts to persuade or compel it to 
do so unavailing and distressing to the child, are apt to desist, waiting 



^ For a full description of tlie best forms of electrical batteries for medical purposes, 
the reader is referred to Meyer's work on " Electricity in its Relations to Practical 
Medicine," translated by Hammond (New York, 1869). Among the best and most 
convenient forms of both induction and direct current batteries, are those made by 
Stohrer, of Dresden, which can be had from his agent in London, J. F. Pratt, 420 
Oxford Street. There are also several induction current batteries, of portable size 
and quite reliable and powerful, which are imported from Paris, and can be had at 
the stores of our electricians. 

Among batteries of American make, those of the American Galvano-faradic Manu- 
facturing Company are the most convenient and reliable. 



632 ATROPHIC INFANTILE PARALYSIS. 

until increased power of movement returns: a delay which is too often 
followed by all the steps of the atrophic period. 

To supply the indispensable exercise of the muscles, and in a form 
attractive to the little patients, numerous mechanical contrivances have 
been resorted to. 

While the legs are still almost powerless, some form of baby-jumper 
at the same time delights the child and effectually exercises its limbs. 
When tiie power of motion has returned to a somewhat greater ex- 
tent, we gain the same results even more completely by the use of the 
go-cart or velocipede, a frame or a chair upon wheels, the motive 
power being furnished by the alternate pressure of the rider's feet 
upon a pair of treadles which are connected with the wheels by 
cranks. This imparts such a sense of security and so much pleasure, 
that the child can readily be encouraged to take enough exercise to 
preserve the play of the articulations, and to aid in developing muscu- 
lar power. 

Dr. West makes a single objection to the use of the go-cart; that 
it encourages the tendency to lean very much forward in walking, 
which always exists until after the little patients have learned to walk 
pretty well; he, therefore, advises that, after the child has gained some 
facility in the use of the go-cart, a jacket should be worn, supplied 
with a stout strap before and behind, so that the attendant can con- 
veniently hold them and support the child's weight more or less com- 
pletely, thus enabling it to walk without being thrown forward as when 
stepping in a go-cart. 

In children of from five to seven years even, the use of crutches is 
soon acquired, and it is desirable, so soon as possible, to abandon the 
other contrivances spoken of, and trust the child to its own exertions 
to walk with a pair of crutches. 

When the paralysis affects the arms, precisel}^ the same principle 
should guide us, and every form of persuasion, of stratagem, and con- 
trivance, must be used to induce th© child to exercise the crippled 
member. Trundling a hoop, or raising a weight by means of a cord 
passing over a pulley, furnish good exercise to the arm; or we may 
encourage the little one to use a contrivance, also called a velocipede, 
in which the wheels are turned by handles, instead of treadles, attached 
to the cranks. 

In addition to these forms of exercise, however, it is often found nec- 
essary to employ splints of different kinds, such as Stromeyer's, which 
enables the angle of the splint to be changed without removal from the 
limb, and various modes of extension to counteract the tendency which 
exists to contraction of the paralyzed part. In some cases, indeed, all 
means are powerless to avoid this consequence, and we are obliged to 
resort to the section of the tendons of the contracted muscles and sub- 
sequent extension, though tenotomy should not be performed until 
time has been allowed to show the extent of permanent paralysis, and 
until the conjoined use of electricity and orthopaedic apparatus has 
proved insufficient to restore the limb to its shape. 



FACIAL PARALYSIS. 633 

It may readily be surmised that this orthopsedic plan of treatment is 
one requiring the utmost patience and persistence, and the most loving- 
persuasion and encouragement; for, indeed, it must be pursued, in face 
of all apparent failure, for months and years. Nor must we be satisfied 
during this period with these efforts we are making to restore the 
power of the muscles; but careful attention must be paid to the nutri- 
tion and general health of the child, and we must continue the use of 
the warm douche, in conjunction with the persistent use of electricity, 
of stimulating frictions, and of every remedy calculated to promote the 
general nutrition of the child. 



AETICLE XII. 

FACIAL PARALYSIS. 

Paralysis of the muscles supplied with motor power by the facial 
nerve, is frequently met with as a temporary condition in infants who 
have been delivered by forceps, as a result of the pressure of the blade 
of the instrument upon the nerve as it emerges from the cranium. It 
is by no means rare, however, during childhood, and either appears 
suddenly after exposure to cold, when it is possibly due to pressure 
caused by congestion and swelling of the tisssues around the stylo- 
mastoid foramen; or more gradually, when it is usually due to pres- 
sure from an enlarged gland, or to disease of the petrous portion of the 
temporal bone. 

The symptoms of this affection are so striking that no difficulty can 
exist as to its diagnosis. The eye upon the affected side remains open; 
the power of knitting the forehead and of raising the eyebrow is lost; 
the angle of the nose and mouth on the same side hang down. The 
tears trickle over the cheek, and the conjunctiva frequently becomes 
injected or inflamed; saliva dribbles from the mouth, portions of food 
collect between the teeth and paralyzed cheek, and there is inability 
to whistle, spit, or distend the cheeks with air. During the acts of 
laughing or crying, the face becomes distorted, owing to the immo- 
bility of the paralyzed side, while the antagonistic muscles act strongly 
and draw the features towards the sound side. 

In cases due to an affection of the nerve in its course through the 
petrous portion of the temporal bone, usually depending upon caries or 
necrosis of this bone, there are present, besides the symptoms above 
mentioned, purulent otorrhoea, deafness, diminution in taste on the side 
of the tongue corresponding to the paralysis^ and in some cases unilat- 
eral paralysis of the velum palati. 

The possibility of mistaking simple facial paralysis for hemiplegia 
from cerebral hemorrhage must be borne in mind, though attention to 
the symptoms of the case will prevent any error in diagnosis. Thus 



634 PROGRESSIVE MUSCULAR SCLEROSIS. 

in hemiplegia of cerebral origin, the paralysis is usnally ushered in by 
convulsions and coma; the frontalis and orbicularis muscles are not 
paralyzed; but, on the other hand, the masseters, temporals, and ptery- 
goids, supplied by the fifth nerve, occasionally are, and the tongue is 
protruded towards the paral^^zed side; and, finally, there is loss of 
power in the arm and leg on the .*ame side. 

The prognosis of cases of facial palsy must evidently depend upon 
the cause. When the paralysis is due simply to exposure to cold, a 
cure may be expected, though the affection is often very tedious, the 
paralysis at times persisting for months. But when, on the other hand, 
it depends upon disease of the temporal bone, the prognosis is usually 
unfavorable. 

The treatment must also be modified according to the cause of the 
attack. 

In simple acute cases, the application of hot fomentations to the part, 
or of one or two leeches near the stylo-mastoid foramen, simuld always 
be directed, and is often productive of good results. Later in the affec- 
tion, if the paralysis persists, small blisters should be repeatedly applied 
near the point of exit of the nerve. 

Electricity is here also of very great service, and the same curious 
observation, which was mentioned in atrophic infantile paralysis, as to 
the power of the direct current to excite muscular contractions when 
the muscles have ceased entirely to respond to an induced current, has 
been frequently made in this affection (Baierlacher, Neumann, Ead- 
cliffe, Hillier). 

In addition to these local remedies, the internal use of stiychnia, 
iron, or iodide of potassium, is often followed bj^ benefit. In cases where 
there is reason to suspect that disease of the bone, or scrofulous enlarge- 
ment of the cervical glands, are the cause of the paralysis, the patient 
should be put upon the use of iodide of iron or cod-liver oil. 



AKTICLE XIII. 

PROGRESSIVE MUSCULAR SCLEROSIS OR PSEUDO-HYPERTROPHIC MUSCULAR 

PARALYSIS. 

Definition. — This curious affection is characterized by progressive 
loss of power, which first appears in certain groups of muscles, and ad- 
vances until nearly all the muscles of the body may be involved, while 
at the same time the affected muscles increase in size and firmness 
owing to excessive hypertrophy (sclerotic) of their interfibrillar con- 
nective tissue. The muscular fibres usually present changes them- 
selves, and at a later stage there is a process of fatty degeneration or 
accumulation in the newly formed interstitial tissue. 



HISTORY — CAUSES. 635 

History; Synonyms and Frequency. — True progressive muscular 
atrophy is extremely rare in young children ; and among the cases 
■which have been described, as by Mer\^on/ a certain number seem to 
belong to the disease now under consideration. The merit of having 
first clearlv recop-nized and described the distinctive features of this 
latter atfection, certainly belongs to Duchenne, whose first observations 
were published more than twelve years ago.^ Since then cases have 
been reported in rapid succession until the number now upon record 
must exceed 60. The disease cannot therefore be regarded as a very 
rare one. There have been, we believe, but four cases placed upon 
record in this country- : by Drs. Ingalls and AYebber,^ by one of our- 
selves,* by S. Weir Mitchell.^ and by E.M. Estrazulas.^ In addition to 
these four cases, of which we have had the opportunity^ of carefully 
studying three, a fifth case has recently been admitted to our ward 
in the Children's Hospital, presenting the characteristic symptoms in a 
most marked degree. 

Various names have already been applied to the affection. It was 
originally called "hypertrophic paraplegia of infancy,'' by Duchenne, 
but he has since substituted the terms, paralysis with muscular degene- 
ration (paralysie myosclei'osique), or muscular paralysis with apparent 
hypertrophy (paralysie musculaire pseudo-hypertrophique). It has 
also been called "lipomatosis luxnrians musculorum progressiva'^ 
(Heller); lipomatous muscular atrophy (Seidel) ; progressive muscular 
paralysis, as a result of hypertrophy of the interstitial fatty tissue 
(Niemeyer); fatty muscular hypertrophy (Bergeron and Lutz) ; and, 
finally, progressive muscular sclerosis (Jaccoud and others). We much 
prefer this latter term, since it expresses the true pathological process 
which is present, and at the same time does not tend to confound this 
disease with any of the forms of true paralysis, from which it is, in 
reality, clearly distinguished by the facts that its essential feature is a 
progressive change in the structure of the muscle, and that the loss of 
power is dependent upon the change in the muscular tissue, and is not 
primary, as in all true palsies. 

Causes. — The essential causes of progressive muscular sclerosis are 
unknown. There are, however, some influences which exert marked 
control over its occurrence. One of the most important of these is 
early age, since in a very large majority of cases the disease begins in 
childhood, and has even appeared in some cases to be congenital (Nie- 
meyer). Although, however, it must be distinctly classed among the 
affections of childhood, it has been shown (Benedikt, Lutz, and Lay- 
cock) to occasionally occur in adult life. Sex also exerts a powerful 

1 Pract. and Path. Kesearches on Paralysis. London, 1864, p. 200, et seq. 

2 De I'Electrisation Localis^e, 2eme ed., Paris, 1861. 

3 Boston Med. and Surg. Journal, Nov. 1870. 

^ Clinical Lecture on a case of Progressive Muscular Sclerosis, by William Pepper. 
Philadelphia Med. Times, June 15th and July 1st, 1871 

^ Photographic Review, October, 1871. 

^ Obstetrical Journal of Great Britain and Ireland (American Supplement, p. 81), 
Sept. 1873, voh i, No. 6. 



636 PROGRESSIVE MUSCULAR SCLEROSIS. 

influence: of 45 cases collected by Estrazulas {loc. cit.'), in which this 
point was noted, it occurred only 7 times in females. 

The curious fact has also been observed, that several children in the 
same family are apt to be aifected, probably indicating some hereditary 
tendency. Euleuburg^ is consequently inclined to regard the disease 
as dependent upon some congenitally defective formation of the central 
nervous s^^stem, probably in the cells of the gray substance of the 
spinal cord. Instances are on record where four brothers were affected 
(Meryon) ; and in another two brothers (Eulenburg); and in still an- 
other by the son of the latter author, in which the affection first showed 
itself in three sisters successively in the eighth year of their age. 

Symptoms. — The disease either begins in early infancy, and is first 
manifested at the time the child should begin to walk, or it makes its 
appearance some years after the power of walking has been acquired. 

The disease usually affects first the muscles of the legs, and advances 
upwards; in Niemeyer's case, on the other hand, it began in the gluteal 
muscles, and subsequently affected all the muscles of the lower extrem- 
ities. The early symptoms are, therefore, connected with walking, and 
it is observed either that the child does not begin to walk until very 
late, and then walks imperfectly, or that, having walked well for several 
years, he begins to be readily tired by standing or walking, and soon 
presents peculiarities in his gait. When the disease is fully established, 
though before it has advanced far, the mode of walking and standing 
are quite characteristic. The patients find that, without some support, 
these operations become more and more difficult and painful, and that 
they are subject to frequent falls. In order to maintain their equilib- 
rium while standing or walking, the lower dorsal and lumbar spine is 
arched forwards, while the upper part of the spine, the shoulders and 
head are bent backwards, frequently to so great an extent that their 
point of equilibrium falls behind the pelvis, thus producing the deform- 
ity known as " ensellure " or " saddle-back.'^ The legs are widely sep- 
arated, and in walking the body is inclined laterally towards the leg 
which rests on the ground, thus producing a characteristic balancing of 
the body during progression, while the arms are swung about, and the 
legs are advanced by jerks, describing a small arc. 

While this impairment of strength and power of progression is devel- 
oping, the affected muscles undergo remarkable changes. For a time 
the}^ may be noticed merely to cease developing and increasing in size, 
or, more rarely, as in the case reported by one of ourselves (loc. cit.'), 
and which is quoted below in full, they may present a well-marked 
stage of atrophy. After the stage of muscular weakness has lasted for 
a variable time, from a few months to two or even three years, whether 
or not there has been any noticeable atrophy of the affected muscles, 
a progressive enlargement of them makes its appearance. This usually 
affects the gastrocnemii first, then the glutei, the lumbar muscles of 
the spine, of the trunk, and finally the muscles of the arms, and even 

1 Virchow's Archiv., liii, 361. 



SYMPTOMS. 637 

of the face. This order is not invariably followed, and in by no means 
every case is the affection of the muscles so universal. The apparent 
hypertrophy may occur in nearly all the muscles which have shown 
weakness, but in general, according to Duchenne, it does not, and may 
even be limited to a ver\^ small number of them. The same observer 
{Joe. cit.), thus describes the appearance of the muscles after this con- 
secutive enlargement has occurred. 

..." The hypertrophied muscles are firm and elastic; they become 
ver}' hard while they contract, and show all the relief or projection 
which properly belongs to their contracted state; they then appear to 
form a hernial protrusion through the integument, which is very thin ; 
moreover, their great size shows off the apparent smallness and deli- 
cacy of the joints at the knee, ankle, &c." 

When this pseudo-hypertrophy is marked, and affects many muscles, 
it gives a most curious aj^pearance to the children. Niemeyer speaks 
of his patient as looking " as if he had the body and head of a weak 
child on the hips and thighs of a strong man ;" and J. Lockhart Clarke, 
in describing one of Duchenne's patients, says : " He looked like a little 
Hercules. Every visible muscle of the body, except the pectorals, was 
enormously developed; his head, even, appeared swollen, and the tem- 
poral muscles stood out like convex shells. Yet, when the poor boy 
atteuipted to walk, he labored to get along, presenting the most gro- 
tesque appearance; and when laid on the ground, he was wholly un- 
able to rise by his own unaided efforts."^ 

Dr. Mitchell (loc. cit.) calls attention to the fact, however, which we 
have also observed, that the enlargement of the calves is lower down 
than would be the case in excessively developed, but well-formed limbs. 

The marked enlargement of the muscles of the calves is often attended 
with forced extension of the feet, producing double pes equinus or 
equino-varus. In the case reported by Estrazulas {loc. cit.), there ia 
also marked enlargement and retraction of the posterior muscles of the 
thigh, with atrophy of the extensor group, so that there is forced 
flexion of the legs, rendering the boy unable to stand at all. Knoll^ 
also describes such contractions in the enlarged muscles, but they are 
not usually present. According to Berger,'^ fibrillar contractions are 
of constant occurrence in the affected muscles : this does not accord 
with our own observations, nor with many of the reported descriptions 
of the disease. 

The electrical condition of the affected muscles is peculiar. Fre- 
quently the results, when tested with faradaic currents, are different 
from those obtained with galvanism. The results also vary at differ- 
ent stages of the same case. Usually the muscular contractility, as 
tested by faradization, is impaired in all the affected muscles, those 



1 Trans, of London Path. Soc, vol. xix, 1868, p. 6. 

2 Wien. Med, Jahrb., 1872; and in Syd. Soc. Bienn. Ketrospect, 1871-72, p. 71. 

3 Deut. Arch. f. Klin. Med., March, 1872, Bd. ix ; Hft. 4, 5, p. 363. 



638 PROGRESSIVE MUSCULAR SCLEROSIS. 

which are hypertrophied, however, contracting more actively than 
those which are atrophied. The galvano-contractility is also slightly 
impaired. The electro-muscular contractility has been found unim- 
paired in the earlier stages of the disease; but later it diminishes, the 
muscles continuing, however, to respond actively to galvanism after 
they have partly lost their power of responding to faradization. 

Electro-muscular sensibility has been found normal or impaired in 
different cases: in one of our patients it was diminished to faradiza- 
tion, but remained acute to galvanism. 

The skin over the affected parts often presents a marbled or mottled 
appearance. In one case that we have seen (described b}^ Mitchell, 
loc. cit.), the mottling " consists of spaces of pallid skin surrounded by 
quite regular circles of congestion, which affect an irregular polygo- 
nal shape." The skin is usually thin and delicate, and can be easily 
lifted from the muscles. Disorders of the cutaneous sensibility have 
not been usually found, but Berger (loc. cit.) describes violent neuralgic 
pains and formication, followed at a later stage by anaesthesia. 

The temperature of the parts is lowered. This can be distinguished 
by the hand, and has been found, on careful thermometric study, by 
Mitchell, to be as follows: Left axilla, 97. 5*^ ; right axilla, 97°; peri- 
neum, 94.5°; right calf, 91.5°; left calf, 91°; and Estrazulas, in the 
case observed by him, reports the temperature in both axillae 98° ; on 
right calf, 91|° ; and on left calf, 91°. 

The following case, which has already appeared in print (loc. cit.), 
may be quoted as an illustration of many of the previous remarks: 

W. E., set. 20, was admitted to the Philadelphia Hospital, April 19, 1871. He was 
born in Yirginia, and has resided there or in the District of Columbia until the 
present time. His parents are both dead, — his father from cholera, his mother from 
some unknown cause. He had two sisters and a brother, all of whom are dead, — two 
from unknown causes; but one sister had paralysis (apparently hemiplegia) and was 
unable to walk for some time before her death. The patient himself was a delicate 
and weakly child so far back as he can recollect. He never suffered either from 
malaria or rheumatism. He was engaged in the country on a farm, and his strength 
was overtasked by heavy lifting. He never, however, met with any injury. Six 
years ago he began to notice gradually increasing loss of strength in the legs, which 
progressed so slowly that for eighteen months he was still able to run about, though 
not so actively as other boys. He was not obliged to use a cane until two years ago, 
and since then only in walking considerable distances. This gradually increasing 
debility was attended with no pain, formication, or subjective sense of change of 
temperature in the legs. There were also no contractions or cramps of the muscles. 
The progressive debility had not continued long before he noticed that it was neces- 
sary, when he was standing or walking, to throw his shoulders back and protrude his 
abdomen and lower part of the thorax, thus showing that the muscles of the back 
were affected at a very early date. During this early period he could walk quite 
naturally, but in running he threw his shoulders far back and stretched his legs widely 
apart ; he assumed the same position also in going up an elevation. Two years later 
the muscles of the arms became affected in the same way as those of the legs and 
back. Dui-ing the first three years he merely noticed that the legs did not grow as 
they should do, but afterwards atrophy began, first in the muscles of the calves, 



CASE. 639 

shortly after in those of the thighs and of the back, and soon afterwards in those of 
the shoulders and arms. About two years ago, after the atrophy of the muscles of 
the calves had become very marked, he noticed that the}^ began to increase in size, 
and this growth has continued until they have acquired a size much greater than they 
ever had previously. This process of renewed growth next appeared, about one year 
ago, in the muscles of the forearm, and has continued at a slow rate. During all this 
time his weakness has steadily increased ; he has, however, never been kept in bed 
by it, but has been able to get about feebly b}^ the aid of a cane. He has never had 
a sense of constriction about any part of the body. His appetite throughout has been 
good, his digestion fair, and bowels regular. His urine has always been passed with 
ease, and has merely been noted to be occasionally yellow. About one year ago he 
was seized, without any apparent cause, with a severe epileptic convulsion, and since 
that time he has had similar attacks at intervals of from fifteen to thirty days. He 
has usually been unable to tell when these fits were coming on, but occasionally he 
has had a strange feeling in the head, and has thought of foolish things, before the 
attacks. The fits have been attended with entire unconsciousness, sudden falling to 
the ground, and muscular convulsion. He has usually been half a day in entirely 
recovering from them. He has never had more than two convulsions on the same 
day. 

Present condition. — His expression is natural, mind active, and special senses unaf- 
fected. The muscles of the face are not involved, and their action is perfect. His 
tongue is clean and moist, appetite fair, digestion easy, and bowels regular. There is 
no enlargement of the abdominal viscera. The urine is normal and secreted in nor- 
mal quantity. His respirations are easy, twelve in the minute, chiefly diaphragmatic : 
the vesicular murmur is soft and healthy. The cardiac sounds are normal. The 
pulse is 75, in the recumbent position. 

Muscula)' system. — The muscles of the neck (sterno-cleido-mastoids and extensors of 
the head) are of fair size, and their movements are strong and free. The trapezii are 
feeble, and he retracts the shoulders with difficulty and feebly. The pectoral muscles 
are moderately wasted and feeble. The scapular group of muscles are less wasted 
and the scapulae do not project markedly from the thorax, so that the serrati magni 
are probably not much wasted and enfeebled. The deltoids are extremely wasted 
and he is unable to raise either arm. within thirty degrees of the horizontal plane ; 
when the arm is raised, there is a marked depression below the acromion process. 
The biceps muscles are also extremely wasted, and he is able to flex the forearm only 
a little beyond a right angle. The triceps muscles are also very feeble, and the long 
head of each is greatly wasted, while the external and short heads appear as quite 
prominent fleshy masses. 

The forearms seem unduly large in comparison with the atrophied arms, and are 
in reality larger than they have ever previously been. They have, moreover, a pecu- 
liar blunt and swollen appearance, owing to the sudden enlargement of the muscles 
above the wrists. The atrophy of the forearms seems never to have reached the de- 
gree attained elsewhere, so that the degree of consecutive hypertrophy has not been 
so marked as in the calves. The grasp of the hands is decidedl}^ weaker than would 
be expected from the size of the forearms, that of the right being much weaker than 
that of the left hand. There has been no atrophy of the muscles of the hands. 

When he sits up in bed, he is only able to hold the shoulders back with effort ; there 
is increased bowing forward of the vertebral column, with absence of the lumbar de- 
pression. There is decided wasting of the erector spinae muscles on either side. When 
lying in bed, the lumbar spine is raised, so that the obliquity of the pelvis and hypo- 
gastric region is increased. The muscles of the abdomen and thorax are not wasted, 
and preserve good strength. 

When he is lying down, the feet are strongly extended and adducted (equino-varus), 
so that the toes point towards each other, while the soles rest on the bed. There is 
great prominence of the tarsus. The muscles of the thighs are all much wasted, as 



640 PROGRESSIVE MUSCULAR SCLEROSIS. 

are those of the buttocks. It is with difBculty that, when lying; down, he can draw 
u^D the legs by the action of the flexor muscles. He has much more power of extend- 
ing them by the quadriceps extensors. The rotators, abductors, and adductors of the 
thighs are much less affected. He can move in bed only by a wriggling motion. 

The calves appear as large as those of a vigorous man, contrasting very strangely 
with the wasted thighs. They feel quite firm, even when relaxed, and when he con- 
tracts the muscles they stand out well, and are hard and elastic. The heads of the 
gastrocnemii especially become prominent, standing out like firm subcutaneous tumors. 
He has considerable power of flexing, adducting, and abducting the feet, but the ex- 
tensors are very feeble. The muscles of the right thigh and leg are decidedly stronger 
than the corresponding ones of the left side. 

In rising from the recumbent position into a sitting one, he is obliged to make a 
very strong effort. When about to stand up, he throws his body forward till it 
almost rests on his thighs, and then, placing his hands on his knees and rising a little 
from his seat, he slowly raises his body by sliding his hands up his thighs ; and when 
he has raised himself as far as possible in this way, he places one hand after the other 
on a chair-back or edge of a table, and leans forward. He then, by jerks of the alter- 
nate sides of the body, draws his legs forward, thus assuming more and more nearly 
an erect position. So soon as he approaches this, the legs are widely separated, the 
shoulders thrown quickly back, and the abdomen protruded, and, after tottering a 
few times, he secures his equilibrium in this peculiar position. It is very tiresome 
for him to stand without some support, and when he does so he bears with his whole 
weight on the right foot, the sole of which rests flat on the ground, while the left leg 
is thrown forward in advance, and the heel elevated from the ground. When a sup- 
port is afforded him, he places both hands on it, and leans forward, rising on the balls 
of the feet, so that the heels are raised one-half inch from the ground. In this posi- 
tion he stands for half an hour or more at a time. The muscles of the calves are con- 
tracted and thrown into prominent relief. 

In walking, as in standing, the shoulders are thrown very far back, and the lum- 
bar depression is rendered very deep ; the arms hang down by the sides, coming de- 
cidedly behind the line of the buttocks. The legs are kept quite widely apart. He ad- 
vances each one by resting his weight on the opposite foot, and then swinging forward 
the whole side, the foot describing a slight arc. At the moment of thus swinging for- 
ward either leg, he rises slightly on the opposite foot. While standing on the right 
foot, the whole sole rests on the ground, though the heel merely touches it lightly ; but 
when his weight is thrown entirely on the left leg, the left heel still does not touch 
the ground. The effort of advancing each leg is evidently great; the muscles of the 
thighs tremble and quiver, but those of the calves contract forcibly and are thrown 
into bold relief. Walking is very tiresome, and gives him pain and soreness in the 
back. Xo fibrillar contractions are seen in any of the muscles. 

Electric examinaiion, April 23d, 1871. — The muscles of the forearm (tested on the 
right side) contract well under a faradaic current of rather unusual strength; they 
also respond well to faradization of the brachial plexus. Electro-muscular sensibility 
is not acute, though this may be a mere individual peculiarity. The muscles of the 
arm, the pectoralis major, and the trapezius all contract on faradization, whether 
direct or applied to their motor points. It requires rather too powerful a current to 
produce these effects. A still more powerful current is required to induce contrac- 
tion of the thigh muscles, but they all respond, though feebly : the sensibility to the 
current is impaired. The contractions of the flexors of the leg on the thigh are the 
most feeble, and are obtained only by very strong currents. The muscles of the leg 
respond more actively than the muscles of the thigh, whether the electrode is placed 
over the nerve in the thigh, or on the motor point of the muscle, or directly over its 
body. 

When tested with a galvanic current, the muscles of the calves of the legs contract 
with each interruption and renewal of a current of rather unusual strength (twenty 



CASE. 641 

cell?, Stohrer), and electro-muscular sensibility is acute. The muscles of the thighs 
also respond, but with more difficulty, to the galvanic current. 
The following measurements were taken : 

Eight arm, greatest circi;mfereiice, 7 inches. 

" forearm, circumference one inch above wrist, 6 

at middle, 834 " 

" » " three inches below elbow, point of greatest thickness, . S]4 " 

" thigh, circumference hand's breadth above knee, 10|4 " 

" " " at middle, UK " 

" " " close to perineum, 12% " 

" calf, " at thickest part, . . ' 12% " 

Left arm, corresponding point, 7 

" forearm, " " 6 

»ys " 

8% " 

" thigh, " " lOK " 

" " " " 11% " 

" " " " 12% " 

" calf, " " 123^" 

The general sensibility is everywhere normal, and there are no subjective disturb- 
ances of sensation. The circulation of the extremities is somewhat feeble, and both 
hands and feet readily become bluish on exposure to cold. The color of the surface 
is, however, everywhere normal, without any mottling. 

April 30. — He had to-day an epileptic attack, with frothing at the mouth, general 
muscular spasms, and unconsciousness, lasting for eight minutes. There was deep 
stupor and sleep for four hours subsequently, and he did not entirely recover until 
the following morning. The fit was preceded for about a minute by the foolish fan- 
cies he has frequently had before. 

Ordered syr. phosphat. comp , f^ij, t. d. Faradization of arms and legs on alter- 
nate days. 

A fragment removed by Duchenne's '' emporte-piece " from the left deltoid was of 
a slightly pale reddish color. When examined microscopically, a large majority of 
the fibrils showed distinct, though often fine and delicate, transverse striation. In 
a few instances, striation was entirely absent, the fibrils looking homogeneous and 
much like ground-glass cylinders. In a very few fibrils, also, distinct longitudinal 
striation was visible, and in others there was multiplication of the nuclei in the sar- 
colemma. In not a single fibril was there any trace of fatty degeneration. The 
fibrils varied in size from ^^-^^^ to -^jq^^, or even, in a few cases, y^o^^. The stria- 
tion was particularly faint, or at times even absent, in the largest fibrils. There was 
a large amount of interstitial white fibrous tissue, with abundant granular matter 
containing many oval nuclei. In places there were small collections of minute fat- 
globules or refracting granules. 

Fragments removed from the gastrocnemii presented closely analogous conditions. 
The muscular tissue was merely rather paler red than normal. The muscular fibrils 
varied greatly in appearance and in size. The transverse striation was in some 
fibrils perfectly healthy, but in a majority it was altered, though in various ways. 
Thus, in some it was very faint and difficult to distinguish ; in others, it was wholly 
absent, the fibrils presenting the appearance of fine ground-glass. In other fibrils 
there was a marked appearance of longitudinal striation, due to delicate fibres or 
very fine fusiform cells arranged in the long axis of the muscular fibril. In many 
fibrils there was distinct excess of the nuclei of the sarcolemma, which appeared as 
large oval nuclei with a punctiform nucleus. A few fibrils presented streaks of mi- 
nute fatty granules along their centres, and a very small number were decidedly 
fatty. The muscular fibrils varied greatly in size also. Many were about 2 !,o^' ^^ 
gi^^^ in diameter; but a number were ^-|o''^ to 4^0^^, while others were as much as 
lis^^^ T?o^^> ¥70^^ in width. There was a large excess of interstitial tissue, in places 
taking the form of long, narrow, wavy bands of pure white fibrous tissue ; in others, 

41 



642 PROGRESSIVE MUSCULAR SCLEROSIS. 

appearing as abundant granular stroma, thickly strewn with oval nuclei. There 
was also some curly, elastic fibrous tissue. There was a considerable amount of inter- 
stitial fat, existing as scattered globules, or arranged in patches of large, closely ag- 
gregated fat-globules. In places, isolated muscular fibrils lay imbedded in this fibroid 
tissue so as to be scarcely visible ; but in other places a number of fibrils lay directly 
in contact with each other, forming a little bundle, around which the excessive growth 
of interstitial tissue had occurred. The arterioles and capillaries appeared healthy. 
No nerve-fibrils were detected. 

The patient continued for several months upon the above treatment, and appeared 
to gain slightly in strength. The recurrence of his convulsions was checked by full 
doses of bromide of potassium ; still it could not be said that any material improve- 
ment had occurred, when he left the hospital, and was lost sight of. 

There is iisnallv an entire want of disturbance of the general health. 
The appetite remains good until a late period, digestion is well per- 
formed, and the action of the bowels is regular. JN'either the rectum 
nor the urinary bladder becomes paralyzed. There is frequently an 
entire want of cerebral symptoms, and the mind may be clear until the 
close of the case. In several instances, however, the patients have 
been of feeble intelligence, or even idiotic ; and in the case above re- 
ported, it will be remembered that the disease was complicated with 
epileptiform convulsions. 

Course and Duration. — As will be inferred from the foregoing de- 
scrijition, the duration of this disease is very considerable, varying 
from five to fifteen years, or even more. It may occupy several years 
in reaching its full development, and may then remain at this stage for 
several years, or even until a tolerably advanced jDeriod of youth, but 
finally it is succeeded by a stage in which the loss of power becomes 
more complete and extensive, involving the upper extremities and 
muscles of respiration, and confining the patients to the recumbent 
position. During this fi.nal stage there is a rapid decrease in the size 
of the hypertrophied muscles, and the limbs may even come to present 
an appearance of great atrophy. 

Death usually occurs before adult age from sheer prostration or from 
some intercurrent affection of the respiratory organs. 

Prognosis. — The course of this disease is steadily progressive, and, 
despite the various plans of treatment adopted, usually leads to a fatal 
result. In one case, however, recovery took place, and in one other 
there was some improvement. In the case we have here reported, 
there seemed to be some temporary improvement under treatment. 

Diagnosis. — The diseases from w-hich it is most important to distin- 
guish progressive muscular sclerosis are atrophic infantile paralysis 
and progressive muscular atrophy. In infantile paralysis, however, 
the suddenness of attack, frequently associated with fever or with some 
cerebral disturbance, as convulsions; the occurrence of complete and 
more or less extensive paralysis ; the gradual disappearance of the pa- 
ralysis in some parts, while in others it remains permanent; the dimi- 
nution and ultimate loss of electro-muscular contractility; the occur- 
rence at a later period of fatty degeneration and atrophy of the affected 
muscles, with arrest in the development of the bones and marked de- 
formities; and the entire absence of any secondary enlargement of the 



DIAGNOSIS — MORBID ANATOiNlY AND NATURE. 643 

parts involved, constitute a series of distinctive features so clear and 
decisive as to render the differential diagnosis easy and certain. 

A disease from which it is much more important to carefully distin- 
guish progressive sclerosis of the muscles is progressive muscular 
atrophy occurring in childhood. The especial importance of the rela- 
tions of these two diseases depends on the fact that both are alike dis- 
eases of nutrition of the muscles, thus constituting a group quite dis- 
tinct from all the forms of true paralysis. In both the disease begins — 
usually without any apparent cause — insidiously, and progresses slowly 
but surely. In both the loss of motor power is secondary to the 
changes in the muscular tissue; in both the muscular degeneration and 
consequent loss of power almost invariably progress steadily to a fatal 
result. These two diseases, then, stand related to each other as being 
alike caused by disturbance of the trophic nervous system, but they are 
at the same time most positively separated from each other by marked 
differences in their course and symptoms. 

Thus, in progressive muscular atro^^hy, the disease nearly always 
begins in the upper extremities, and invades subsequently the trunk 
and lower extremities. Indeed, Duchenne has pointed out that when 
this disease appears in childhood, which is quite rare, it usually begins 
in the face, where it produces atrophy of the orbicularis oris and the 
zygomatici, and does not extend to the trunk and extremities until after 
a pei-iod varying from two to three years. It then follows the same de- 
scending course seen in cases occurring in adults. The atrophy usually 
affects the muscles irregularly, so that various deformities and vicious 
positions of the parts involved are developed. Microscopic examination 
shows a progressive fatty degeneration and atrophy of the muscular 
fibrils, and in proportion as this increases there is loss of power and of 
electro-muscular contractility. One further symptom of high diag- 
nostic value is the frequent occurrence of fibrillar contractions in the 
affected muscles, which, although stated by Berger to be of constant 
occurrence in progressive muscular sclerosis, has not been found so by 
ourselves or other observers. Finally, the muscles which have pro- 
gressively atrophi^ed never undergo any secondary enlargement, nor 
does microscoj^ic examination reveal any lesion of the interfibrillar con- 
nective tissue. In all of these particulars, then, progressive muscular 
atrophy differs widely from progressive muscular sclerosis, which is 
almost exclusively a disease of childhood, beginning in the muscles of 
the lower extremities and advancing upwards, producing a peculiar 
mode of standing and walking, and in which the affected muscles, with 
or without a previous stage of atrophy, undergo remarkable enlarge- 
ment, usually without fibrillar contractions, and with preservation of 
electro-muscular contractility till a comparatively late period of the dis- 
ease. The results of microscopic examination, also, as detailed in the 
next paragraph on the morbid anatomy, are entirely di|ferent from 
those observed in progressive atrophy. 

Morbid Anatomy and J^ature. — There is still an urgent need of care- 
ful, skilfully conducted microscopic examinations of the nerve-centres in 



644 PROGRESSIVE MUSCULAR SCLEROSIS. 

this disease. The examinations which have been made up to this time, 
one of which was conducted by Cohnheira, have yielded negative re- 
sults : but we are not aware that, in a single instance, the microscopic 
study has been conducted with the requisite care and thoroughness. 
Until this is done, it is impossible to do more than speculate upon 
the seat and character of the intimate, essential changes. Analogy 
with other diseases of the nutrition of the muscles would seem to sup- 
port the suggestion of Eulenburg, that the pathological origin of the 
disease is to be found in some defective formation or disease of the 
cells of the gray substance of the cord. Berger (Joe. cit.) assumes the 
existence of trophic nerves, and attributes the disease to some disturb- 
ance of their function. Duchenne, on the other hand, ascribes it to a 
paralysis of the vaso-motor nerves; and others again regard it as a 
primitive muscular lesion. 

The condition of the affected muscles themselves has been very care- 
fully studied during life, on small fragments removed by Duchenne's 
trocar^ (emporte-piece), and the results confirmed by examination after 
death. 

When examined by the naked eye, their color is altered, and the 
muscles present either a uniform pale or yellowish appearance, or are 
marked with strij^es of yellow or yellowish-white; on section they 
shine with a dull, greasy lustre. 

The results of microscopic examinations vary somewhat at different 
periods of the disease. The changes affect both the muscular fibrils, 
and. even more markedly, the interfibrillar connective tissue. 

In the early stage, Berger asserts (loe. cit.') that he found in two cases 
an absence of change in the interstitial tissue, and a marked hypertro- 
phy of the fibrils themselves. This enlargement has not, however, 
been constantly observed. The fact of its occurrence, and of its per- 
sistence in some fibrils even in a comparatively advanced period of the 
disease, is confirmed by the observation of Lej'den,^ Estrazulas (loc. 
cit.), Knoll {loc. cit.~), and ourselves. In the later stages, many of 
the fibrils are pale and small, being occasionally reduced, according to 
Cohnheim, to ith their normal diameter; in some places empty sheaths 
of sarcolemma are seen. Many of these fibrils, though altered in size, 
present no other morbid condition, either fatty or granular. Knoll 
observed in some oi ihe broader fibres a tendency to split into two; 
and Martini^ describes a peculiar process of fission or division of some 
of the atrophied fibres. In the cases recorded by Meryon (loc. cit.), 



1 This useful little instrument is shaped like a trocar. The blade is, however, a 
hollow cylinder, composed of two parts, one of which, bearing the point, is fixed, 
while the other can be withdrawn a little by sliding a movable button on the handle. 
The trocar is introduced closed into the substance of the muscle, the button with- 
drawn, so as to open the cylinder and allow a fragment of muscle to project into it; 
the button is then pushed forward, cutting off and securing the little morsel of tissue. 

2 Berl. Klin. Wchnschr., 1866. 

3 Centralblatt, 1871, 641 ; in Syd. Soc. Bienn. Ketrospect, 1871-72, p. 70. 



TREATMENT. 645 

which Avere probably of this form of disease, a granular degeneration 
of the muscular fibres, with rupture of the sarcolemma, was observed. 

The most marked change is, however, in the condition of the inter- 
stitial tissue. It is not known definitely whether this precedes all 
change in the muscular fibrils themselves. But at least by the time 
that enlargement of the muscular masses can readily be detected, there 
is usually, despite the two observations of Berger, marked proliferation 
of its nuclei and hyperplasia of the fibrils. This continues to increase 
until at places the muscular fibres are separated by broad tracts of 
wavy fibrous tissue, interspersed with fine nuclei. At a later period 
this is associated with increasing interstitial fatty accumulation and 
degeneration, which advances with varying rapidity, even leading in 
some cases to such extreme accumulation of fat as to be visible to the 
unaided eye as yellowish streaks. It is probable that the muscular 
fibres may temporarily share the exaggerated nutrition of the surround- 
ing connective tissue, but later, as this interstitial tissue accumulates, 
the fibrils are subjected to severe pressure, and undergo atrophy in 
many instances. The entire process, therefore, seems to be of a strictly 
sclerotic character, so far as the interfibrillar connective tissue is con- 
cerned, but associated with an irregular and as yet undetermined stage 
of true h^^pertrophy of the muscular fibrils themselves. 

Treatment. — The results of treatment in progressive muscular scler- 
osis have so far been highly unsatisfactory. The internal remedies 
from which most benefit may be expected are those which tend to im- 
prove nutrition, and especially to improve the tone of nutrition of 
the nerve-centres. Among these, cod-liver oil, iron, the compound 
syrup of the phosphates, and arsenic, may be specially mentioned. In 
the case reported by ourselves, where there was the complication of 
epileptiform convulsions, benefit was derived from a course of bromide 
of potassium. 

The remedy, however, from which most good is to be expected, is 
electricity. This has been used by Duchenne with great benefit, in the 
form of faradization of the aifected muscles. It is asserted by Bene- 
dikt, that good results have been attained in three cases by the use of 
the direct current, the copper pole being placed over the lower cervical 
ganglion, and the zinc pole along the side of the lumbar vertebrae, by 
means of a broad metal plate. Others have, however, tried this mode 
of treatment for a long time without any success. As, however, no 
more plausible mode of treatment has yet been suggested, we should be 
inclined to adopt it in conjunction with direct faradization of the affected 
muscles, and the use of the internal remedies above recommended. 



CLASS V. 

GENEEAL DISEASES. 

INTRODUCTORY REMARKS. 

This great class includes a large number of diseases, both acute and 
chronic, in which the system at large, including the blood, is affected 
by the morbid process. For the sake of greater clearness and conveni- 
ence, the chronic diseases of this class which appear to us to call for a 
special discussion in the present work, will be treated subsequently in 
a separate class, termed '^Cachectic Diseases." The acute general dis- 
eases may further be subdivided into those which are diathetic^ as rheu- 
matism, and those which are zymotic^ or dependent upon the action of 
some infectious principle introduced from without into the system. 

The zymotic diseases include some which are unattended with erup- 
tion, as mumps, diphtheria, and malaria, as well as the great class of 
eruptive fevers. 



AETICLE I. 



ACUTE RHEUMATISM. 



As it is not designed to enter into a full discussion of the numerous 
affections which merely occur in childhood in common with the other 
periods of life, we shall present but a brief account of rheumatism in 
children, alluding particularly to those points in which it differs from 
the same disease in adults. 

The interest attachino; to rheumatism amono' the diseases of child- 
hood has been of late much increased by the connection which has 
been established between it and chorea. This question has been treated 
of under the head of the latter affection, and we will limit ourselves at 
this place to the discussion of acute articular rheumatism. 

Symptoms. — Acute rheumatism expresses itself in the child, as in the 
adult, by painful inflammation of one or more of the larger joints, 
usually accompanied by a high grade of febrile action. It is probable, 
however, that in the majority of cases in children, the fever is not so 
intense nor the course of the disease so lono;, as in adults. 

The fever, which is one of the most marked symptoms, may precede 
the development of inflammation of the joints by one or two days, or 
may coincide with the appearance of pain and swelling. It is gener- 
ally marked in severe cases, and attended by frequency of the pulse. 



ACUTE rheumatism: duration — CAUSES. 647 

great beat of the skiu, and, usually, copious acid perspirations. The 
heat of the skin and frequencj^ of the pulse constitute a good index of 
the severity of the disease, and we may always apprehend a dangerous 
attack when the temperature rises above 104° or 105°. 

With this febrile action, we find disturbances of the digestive func- 
tions; the tongue is heavily coated, the appetite lost, or nausea maybe 
present, and the bowels are sluggish, the evacuations being dark and 
offensive. 

The local phenomena attending this fever depend upon acute inflam- 
mation of some of the large joints. 

Occasionally the ankles, knee-joints, wrists, elbows, and shoulder- 
joints Avill be simultaneously affected; but in fiir the majority of cases, 
a few onlv of these articulations will be involved, and the others become 
affected subsequently, if indeed they do not escape entirely. But one 
of the most characteristic features of this specific rheumatic inflamma- 
tion, though most marked in the chronic form, is its tendency to shift its 
seat, and we may find the intense pain and heat of one part transferred 
within twenty -four hours to a distant joint. We can rarely learn from 
the little patients the character of the pain which causes such bitter 
complaints; in one mild case, recorded by Eilliet and Barthez, it was 
compared to frequent light blows given upon the affected joints. 

The heat of the inflamed part is always much increased, and it is 
not unusual to find its temperature ranging from 100° to 105° (Ait- 
ken). 

The swelling is generally considerable, so that the shape of the parts 
may be much changed. When the knee-joint is inflamed, the effusion 
may raise the patella from its position on the condyles. 

The skin over the inflamed joints usually presents a more or less de- 
cided blush. 

We must not, however, overlook the fact that the severity of these 
articular troubles is not always commensurate with the rheumatic fever, 
and that frequently, especially in very young children, the local signs 
may be slight or even absent, and the only feature which tends to re- 
veal the real nature of the disorder may be soreness, evinced by cries 
on every attempt to move the patient. 

Duration. — The duration of acute rheumatism varies exceedinglj^. 
According to Eilliet and Barthez, it follows a much more rapid course 
in children than in adults, occasionally yielding at the end of six daj^s, 
and nearly always before the fifteenth day. We have, however, seen 
the rheumatic fever last twenty-one days, and before convalescence was 
fully entered upon, six weeks had elapsed. 

There is a marked tendency to relapses and second attacks in rheu- 
matism, at whatever age it occurs; and we frequently meet with chil- 
dren of twelve or fifteen years of age who have passed through three 
or four acute attacks of this disease. 

Causes. — Age. — Early infancy appears to protect, to a certain ex- 
tent, against this affection. Eilliet and Barthez allude to a case occur- 
ring at the age of seven months; but the earliest age at which they met 
with it was at four years in a single case. 



648 ACUTE RHEUMATISM. 

We have ourselves observed one case in the second year, and several 
others between the close of the second and fifth years. 

The influence which sex exercises upon the frequency of rheumatism 
in childhood seems still undetermined. It is usually stated that boys 
are far more liable to the disease than girls, but in our own experience 
it has been more frequent in girls; and from the register of the Chil- 
dren's Hospital in London (quoted by Tuckwell, St. Barth. Hosp. Eep., 
vol. V, 1868, p. 102), it appears that of 478 cases of rheumatism treated 
during sixteen years, 252 were in females^ and only 226 in males. 

Cold and Dampness. — Of external causes, the most prominent undoubt- 
edly are, sudden vicissitudes of temperature, especially when joined with 
dampness of the atmosphere, whereas the mere degree of coldness ex- 
ercises but little influence upon its development. Of course the action 
of damp and cold is markedl}^ increased by insuflicient clothing. 

Complications. — We have already alluded to the occurrence of chorea 
and cerebral symptoms in connection with rheumatism (see article on 
chorea), and the most important and frequent of all these complica- 
tions, the various inflammations of the membranes of the heart, have 
been treated of under the head of diseases of that organ. 

Prognosis, — Uncomplicated rheumatism in childhood, though at times 
severe, is scarcely ever fatal. When complicated, however, with endo- 
or pericarditis, the gravity of the prognosis must depend upon the ex- 
tent and severity of the inflammation. For although, even when the 
heart is seriously involved, the child frequently survives the acute 
sj^mptoms, it too often bears with it the seeds of premature death, in 
an organic disease of that organ. 

Diagnosis. — The diagnosis of acute rheumatism, after the appear- 
ance of the articular symptoms, can hardly present difficulty. When, 
however, marked rheumatic fever, accompanied merely by vague pains, 
precedes by several days the development of any local symptoms, the 
diagnosis must remain uncertain, or we may be led to regard as rheu- 
matism one of those cases of phlegmon of the deep tissues of the extrem- 
ities, such as is alluded to in the introductory essay of this work. In 
addition to this, we must be careful to distinguish the articular affec- 
tions occurring in pyaemia, or those supervening upon attacks of small- 
pox and scarlet fever, which are probably also of pysemic nature. The 
diagnosis in these cases must be chiefly established by attention to the 
general symptoms and the patient's history; to the occurrence of re- 
peated chills or irregular febrile paroxysms, the diarrhoea, the greater 
degree of prostration and more rapid emaciation, and the more frequent 
I'atality. The joints involved in these latter affections present large 
collections of creamy pus, and the articular cartilages are discolored, or 
eroded and destroyed in patches. 

Finally, Eilliet and Barthez cite a case (from Jour. Mebdomadalre, t. 
ii, p. 260) of hemorrhage under the periosteum of the clavicles, which 
simulated rheumatic inflammation of the sterno-clavicular joints, but 
which could be distinguished by ordinary attention to the general 
symptoms, in case of the occurrence of such a rare condition. 

From our own experience we should think that, during the early 



DIAGNOSIS — TREATMENT. 64:9 

stage of rheumatic fever, the affections with which it might be most 
readily coDfounded, are pleurisy and pneumonia, and typhoid fever. 

The absence of the phj'sical signs of the two former affections, and of 
the diarrhoea and delirium of the latter, should, we think, lead the phy- 
sician to suspect the rheumatic nature of the attack. And if, in addi- 
tion, there should be any fixed pain about the limbs, or unusual soreness 
and pain on being moved, or if any sign of cardiac inflammation be de- 
tected, this suspicion would be confirmed. Thus in a case seen by one 
of us^ where at first the height of the fever and the great thirst led us 
to suspect the existence of pneumonia or pleurisy — of which, however, 
no physical signs could be detected — the occurrence, on the third day, 
of complaints of pain in the right groin, led to a more careful examina- 
tion of the heart, where the presence of a soft, faint mitral murmur, 
declared the nature of the attack. 

Treatment. — The indications for treatment presented by acute rheu- 
matism have been universally recognized as uniform, but the measures 
ado])ted to meet them embi^ace almost all known remedies. 

The prominent indications are : 

1. To aid in the elimination of the rheumatic poison, which has set 
up the specific inflammations and fever. 

2. To relieve pain. 

3. To guard assiduously against all complications, and to aid conva- 
lescence by suitable nourishment and tonics. 

Among the remedies which appear to be most productive of benefit, 
are alkalies^ especially the bicarbonate of soda and acetate of potash, as 
recommended by Garrod ; the bromide of ammonium has also been used 
considerably of late, w^ith apparent benefit. When the fever is very 
marked, nitrate of potash, in carefully graduated doses, is often beneficial. 
The iodide of -potassium is most serviceable in cases of muscular rheu- 
matism, or in somewhat chronic cases of the articular form. Eilliet 
and Barthez assert that they have derived more benefit in the inflam- 
matory complications of rheumatism (endo- and pericarditis, and pleu- 
ris}'), from large doses of this salt than from any other drug. 

The remedies we have ourselves found most useful, consist of acetate 
and bicarbonate of potash with opium, which we are in the habit of 
giving during the acute stage, according to the following formula: 

R. — Potass. Acetat., ^j. 

Potass. Bicarb., ...... '^]. 

Tr. Opii Deodor., gtt. xxiv. 

vel Tr. Opii Cam ph., f:^ij. 

Syr. Zingiberis, f^j. 

Aquae, ad f^iij. 

Pt. sol. S. — A teaspoonful every two or three hours, at four or live years of age. 

Iron^ particularly in the form of Basham's solution of the peracetate 
of iron, should be given so soon as the intensity of the fever has miti- 
gated. The necessity for this remedy is but too often seen in the sal- 
low, anaemic appearance of convalescents from rheumatism, which 
proves the rapid and extreme disintegration of the red corpuscles of 
the blood during an acute attack of this disease. 



650 ACUTE RHEUMATISM. 

When the acute symptoms have subsided, the alkalies may be di- 
minished and withdrawn, and quinia, in the dose of one grain every 
four hours, at the age of five years, may be given in connection with 
opium. 

The following formula is one we frequently use for the administra- 
tion of these remedies in this and other conditions: 



R- — Quinife Sulpli., . 

Liq. Morph. Sulph., 
Acid. Sulph., Dil, . 
Cura9oa, . 
Syrupi, . 
Aqua3, 



. gr, XXIV. 

. gtt. XXX. 

adf|iij. 



Ft. sol. S. — A teaspoonful every four hours, at four or five years of age. 

To fulfil the second indication, the mitigation of pain, opium must 
be given in proportion to the severity of the suffering. It is best given 
in small doses at short intervals, and by administering it in combina- 
tion with ipecacuanha, as in the form of Dover's powder, we derive 
the double benefit of a sedative and diaphoretic action. AYe have 
already given the formula by which we usually direct it in this dis- 
ease. The inflamed and painful joints should be bathed with a seda- 
tive liniment, as of sweet oil, chloroform, and laudanum, and enveloped 
in bats of wool, and then- covered with oiled silk, so accurately applied 
as to exclude entirely the external air. 

In addition to the other remedies, attention must be paid to the con- 
dition of the bowels, and if constipation exists, as is very frequent, mild 
saline laxatives or laxative enemata should be administered as fre- 
quently as required. Anything like purgation, however, should be 
avoided, on account of the excruciating suffering often produced by 
the movements necessary to have a stool. We desire, however, to call 
attention to the fact that young children with this disease may persist 
in lying in one fixed position for even several days, dreading to be 
touched; so that there is added to the inevitable pain of the disease, 
the distress occasioned by the long-continued contact of single points 
of the opposing articulating surfaces. Under these circumstances it is 
wise, and greatly promotes the comfort of the patient, to gently change 
the angle of the limbs by arranging pillows so as to support them and 
alter their direction. 

In regard to the last indication — the prevention of complications — 
the most important means is the avoidance of all exposure of the pa- 
tient to damp or to changes of temperature. In the fulfilment of this, 
the greatest care must be paid to the temperature of the sick-room, to 
the clothing of the patient, and to the mode of conducting all our ex- 
aminations. Dr. Chambers, in his admirable lectures upon this subject 
(Clinical Lectures, American edition, pp. 156, 177, &c.), dwells with 
special force upon this point, and enjoins the exclusive use of blankets 
and flannels for the bedding and clothing of patients with rheumatism, 
and gives the following summary of his observations of the effects of 
this precaution alone in the treatment of nearly two hundred cases of 



DIPHTHERIA. 651 

rheumatism: "That bedding in blankets reduces from sixteen to four, 
or by three-fourths, the risk of inflammation of the heart, diminishes 
the intensity of the inflammation when it does occur, and diminishes 
still further the danger of death by that or any other lesion." 

The importance of confinement to bed in this disease is diflficult to 
overestimate; the inflamed condition of the joints absolutely demands 
it, and the tendency to cardiac inflammation warns us to save the 
heart all unnecessary exertion, which strict attention, as above recom- 
mended, to the equable warmth of the surface, effects better than any 
other means. 

As to the diet in this affection, we must be guided by the acuteness of 
the symptoms and the condition of the patient. If the fever be marked, 
and the child vigorous, a diet chiefly consisting of milk and water is 
best suited to the early part of the attack, but so soon as the febrile 
stage has passed off, or when the patient is of feeble constitution, we 
may give soft-boiled eggs, and meat-broths, with advantage; and fre- 
quently we will find concentrated nourishment and a moderate amount 
of stimulus required towards the close of the case. 

Complications. — In those cases where, despite our precautions, the 
membranes of the heart are threatened with inflammation, as evinced 
by sudden pain in the cardiac region, frequency of pulse, and oppres- 
sion — even before the development of any murmurs — we should lose 
no time in employing local depletion by leeches or cups, abstracting as 
much blood as the urgency of the symptoms and the vigor of the con- 
stitution justify. After the removal of the cups or leeches, warm mush- 
poultices should be applied steadily over the whole prascordial region. 



ZYMOTIC DISEASES. 

Under this title, as already stated, we include those acute general 
diseases which are dependent upon the action of some infectious mor- 
bid principle introduced into the system from without. They embrace 
a non-eruptive group, of which we shall describe diphtheria^ mumps, and 
malaria, and the group of eruptive fevers. 

AETICLB 11. 

DIPHTHERIA. 

Definition; Synonyms; History; Frequency. — Diphtheria is an 
acute febrile, moderately contagious, and infectious asthenic blood dis- 
order, occurring both endemically and epidemically; without character- 
istic eruption, and distinguished by a disposition to the formation of 
false membranes upon inflamed mucous surfaces, especially in the 
fauces, or upon abrasions of the cutaneous surface. 

It is the disease called by the older writers, angina maligna or gan- 



652 DIPHTHERIA. 

grenosa; cynanche maligna; garotillo; angina suffocativa, under which 
name it was described by Dr. Samuel Bard, of New York, in one of 
the best of the early essays upon this subject {Tra?is. Amer. Philos. Soc, 
vol. i). 

It is, indeed, thought probable, that the history of this affection can 
be traced back to a period beyond the time of Hippocrates; but un- 
questionably the writings of Aretseus, who flourished in the second 
century of the Christian era, contain a distinct description of this ma- 
lignant sore throat. He describes it under the names of ulcus Syria- 
cum and malum iEgyptiacum. 

From this period, there is quite frequent mention of the disease in 
the works of medical writers; the earliest account of its appearance in 
modern times being given by Hecker, who describes an epidemic of it 
that prevailed in Holland, in 1337. 

About the middle of the last century, it prevailed in Paris, where it 
was described by MM. Malonin and Chomel; and in some parts of Eng- 
land, where it was studied and described by Fothergill, though it is 
now doubted whether the disease to which he refers was not more 
nearly allied to scarlatinous angina. 

The first full description of this affection published in this country, 
was the paper, already referred to, by Dr. Bard, based upon an epi- 
demic which appeared in 1771; the views advanced in which have been 
universally recognized, even to the present day^, as most clear and just. 

From that time, the complaint seems to have attracted but little at- 
tention, until its occurrence at Tours, in 1818, and subsequent years, 
called forth the treatise of Bretonneau in 1826, in which he gave the 
first precise notion of the disease, and bestowed the name diphtherite 
upon it. 

Since then it has occurred frequently epidemically in France; in 
1857 it appeared almost simultaneously in England, and in the extreme 
western part of our own country, and from that time has occurred in 
the form of epidemics of greater or less extent and severity, in the most 
varied climates and seasons, in almost all known parts of the globe. 

Diphtheria, the name by which this epidemic pseudo-membranous 
angina is commonly designated, is a synonym of the word diphtherite, 
originally used by Bretonneau in his treatise on this subject. 

Ai(pOspa and A'.(fdtpuq both mean "the prepared skin of an animal;" 
and Ai(pdepiTr^q and Ai<pdspLaq signify alike, " that which is covered with a 
skin or membrane." 

No cases of death from diphtheria in Philadelphia are reported in 
the annual lists of mortality published by the Board of Health, until 
the year 1860. In the preceding report, however, Dr. Jewell mentions 
that several severe cases had occurred, some of which had proved fatal. 
One of us can, however, assert from his personal experience, that well- 
marked cases of diphtheria were of not rare occurrence in this city for 
a number of years before that time, but were reported under other 
names, and usually as either croup or angina. 

It is probable, however, that the disease did not prevail at all exten- 



CAUSES AND NATURE. 



653 



sively previously to its great outbreak in 1860, as may be seen by a 
reference to the number of deaths from croup and scarlatina, returned 
for the years preceding and subsequent to that date. 



TOTAL XUMBER OF DEATHS FKOM 





Scarlatina. 


Croup. 


Diphtheria 


1855, . 


. 163 


265 




1856, . . 


. 992 


268 




1857, . 


. 704 


256 




1858, . 


. 241 


292 




1859, . 


. 232 


312 




i860, . 


. 206 


354 


307 


1861, . 


. 329 


304 


602 


1862, . 


. 461 


258 


325 


1863, . 


. 275 


444 


434 


1864, . 


. 349 


455 


357 



The total number of deaths from scarlatina, from 1855 to 1859 inclu- 
sive, were 2332; from 1860 to 1861 inclusive, 1620, or 712 less than in 
the previous period. 

The total number of deaths from croup from 1855 to 1859 inclusive, 
were 1393; from 1860 to 1864 inclusive, 1815, or 422 more than in the 
previous 5 years. And, further, during the latter 5 years, 1860 to 1864, 
the deaths from diphtheria amount to 1925. 

Causes. — In regard to the epidemic and occasionally endemic nature 
of diphtheria, the evidence is unanimously favorable, but it is still, to 
a certain extent, an open question as to how far it possesses contagious 
and infectious properties. 

ISTumerous authorities might be cited in favor of either of these to the 
exclusion of the other; but the evidence adduced convinces us that diph- 
theria is both contagious and infectious also, though to a moderate de- 
gree only. 

Bard, Trousseau,^ Guersant, Yalleix^ (who has himself fallen a victim 
to this disease), Eilliet and Barthez,^ Wood,* Empis,^ and many others, 
attest to its contagiousness; and we have ourselves seen unmistakable 
instances in our own practice. 

Bretonneau^ also maintains strongly the infectious nature of diph- 
theria, and holds that it is transmitted directly by contact with the mor- 
bid product generated by the local disorder, i. e., the pseudo-membrane; 
and it must be admitted that the cases now on record, in which the 
disease has been so transmitted, are too clear and well authenticated 
to permit of doubt. 

Apart from these well-ascertained properties, nothing is as yet known 



1 Clin. Med , 2eme ed., 1865, t. i, p. 385. 

2 Guide du Med. Prat., 4eme ed., 1861, t. i, p. 530. 

3 Mai. des Enfants, 2emeed., 1853, t. i, pp. 343-369. 

4 Pract. of Medicine, 6th ed., 1866, vol. i, pp. 505-525. 

5 Memoirs on Diphtheria (New Syd. Soc. ed., 1859), p. 332. 

6 Id. Op., pp. 127 and 177. 



654 DIPHTHERIA. 

with regard to the general conditions which favor its production ; and 
it appears to have prevailed with equal severity in healthy and un- 
healthy situations; in damp marshy districts and in dry hill}^ regions; 
in the crowded filthy houses of great cities, and in sparsely populated 
villages; in the depth of winter and in the intense heat of summer. 

JS^or can it yet be positively asserted (although it is probably true 
with regard to diphtheria, as in the case of other zymotic diseases), 
that children of feeble constitution and those subjected to bad hygienic 
conditions, or debilitated by severe illness, are particularly exposed to 
it, especially in the sporadic form. 

The effect of local causes, of a depressing character, upon the produc- 
tion of diphtheria, was investigated by Dr. Ballard,^ in regard to 57 fatal 
cases. Inquiries at the houses where the 57 deaths had occurred, 
showed that in 24 instances the houses were damp, and that defective 
drains or some similar cause gave rise to offensive smells; in 4 houses 
the inmates were overcrowded, and the ventilation deficient; in 8 cases, 
the drinking-water was foul, or there was some noxious accumulation; 
and in 25 cases, nothing whatever could be discovered amiss in the hy- 
gienic condition of the houses. 

It is certain, however, that occasionally diphtheria appears in a spo- 
radic form, and isolated cases occur which can be attributed to no known 
cause whatever. 

We subjoin a table of the mortality from croup and diphtheria in this 
community during the seven years from 1862 to 1868 inclusive; upon 
which we base, to a great extent, the remarks which follow as to the 
causation of the latter disease. 

Season. — As we have already remarked, the influence of season upon 
the prevalence of diphtheria is comparatively slight, and there are 
numerous records of epideinics occurring in the summer, as well as in 
the winter months. Notwithstanding, however, it will be seen that in 
our own city the mortality from diphtheria does not vary very much 
during the months from September to March inclusive, whilst during 
the other five months it falls oft^ from thirty to fifty per cent., the mini- 
mum mortality usually occurring in June. We have before had occasion 
to allude to the difference, in this respect, between diphtheria and croup, 
which latter disease shows in the clearest and most marked manner the 
direct influence of season upon its frequency. 

l?hus croup is far most frequent during the three months of Novem- 
ber, December, and January, and, with the exception of February, be- 
comes less and less frequent as you leave these months in either direc- 
tion, until during July, the hottest month of our year, it falls to even 
less than one-fourth of its maximum frequency. During the same 
month, diphtheria, whose maximum mortality is one-third less than 
that of croup (both maxima occurring in December), causes more than 
half as many more deaths than croup does, the proportion being 16.3 
to 10. 

1 Med. Times and Gaz., July 23d, 1859. 



MORTALITY TABLE OF CROUP AND DIPHTHERIA, 



655 





00 

CO 

CO 




00 

CO 


O 
CO 


id 


C5 


on 

CO 


1—1 


CO 

o 


CO 


CM 

CO 

CO 


CM 

CM 

00 
CO 




UBaM 


o 


o 

Oi 
00 
CO 
CO 


00 


o 
CM 


o 


o 

2 


o 


CO 
CD 


o 

CO 
00 

CO 


o 

CO 


§0 
CO 


o 

CO 






il 


SI 


CO 




CO 




CO 

CO 


CO 


CO 

CO 
rH 


CD 
CO 


CO 
CO 
CM 


CO 
CM 


oo 

CM 


CO 

00 
CSl 




P< CO 

g o 

5 - 


Tl 


t- CO 

?3 g^ 


I— 1 T— 1 


o 


00 

d 

T— 1 


CO 




CO 

00 
CO 


•<* 




CO 

CO 
CO 


^1 


c^ 


t~- 


^ 


-N 


o 


CM 


CO 


^ 


r~ 


00 


C^l 

rH 


CM 

CM 


GO 


li- " 


CO 

I— I 


O 


- 


O 


Ttl 


00 


o 


CO 
CM 


C<1 


CM 
CO 


CO 




1>^ 

1 


41 i ,- 

5|| - 


Oi 


t^ 


o 


Oi 


CO 


t^ 


00 


o 


T—l 


00 


rH 

I— I 


00 


2 




CO 


o 

CM 


CM 


CM 


CD 


CO 


CO 


Tfl 


CM 


CO 


lO 
CO 


lO 
GO 

I— I 




CO 

1 


1 rt ' 


t— 1 


Tq 


00 


Ci 


CM 


CM 

rH 


lO 


CO 


CO 


00 


■o 


2 


2 


CO 


CO 


^ 


CO 


CM 


- 


T}H 


CM 


■* 


CM 

CM 


CM 


00 


i 




o 

1 


5| 


CO 
CO 




S 


CM 


CM 


s 


o 




CM 


lO 
CM 


CM 


to 

CM 


CM 


2 




g 




CO 
CM 


CO 
I—: 


CM 

I— 1 


lO 

I-H 


T-H 


CM 


CO 
CO 


CO 


CM 
CO 


00, 


•CO 
CO 




I— 

CM 


O CO 
•7^ ^ 


o 


t^ I— 1 

CM CM 


CM 


o 

CO 


CO 




CO 


'tl 

CO 


to 
CO 


o 
o 


o 


CO 


CM 


CO 
CO 


^ 


Oi 


rH 


I— 1 


CO 


CO 
CO 


o 


o 


lO 


CO 
CO 

00 


4i 


CO 




^ 


CO 


r— 1 


CO 

T—l 


CO 
CO 


CO 


00 

CO 


CO 
CO 


CO 


CM 

CO 


CO 


o 


CO 
CO 




^ 


CO 


- 


t- o 

1— 1 '^ 


CM 

—1 


s 


as 


05 
CO 


CO 


CO 


r4 

CO 
GO 




o 

CO 


O 


CO 
CM 


CM 


CM 
CM 


CM 

I-H 


CM 


CM 


CM 


O <M 

rji CO 


C5 
CM 


lO 
CM 
00 


2 
o 




CM 


05 
CM 


f— 1 


t- 


t- 


00 


Jt- 


CO 


00 


CO 
CO 


CO 


i 


o 


C 






< 






^ 
^ 


< 


g 

02 


o 

CJ 

o 


s 

> 


s 

o 


1 



656 DIPHTHERIA. 

Sex appears to have absolutely no iDfluence upon the frequency of 
diphtheria, since of 1804 fatal cases occurring in this city during the 
above seven years, 901 were males, and 903 females. 

Age. on the other hand, unquestionably exerts a very strong pre- 
disi:)Osing influence, a large majority of all recorded cases occurring 
between the ages of one and eight years. 

Of the 1804 cases in our table, 190 occurred under the age of one 
year; 335 between one and two years; 725 between two and five years, 
and 355 between five and ten years. Although the liability thus dimin- 
ishes, in an uncertain ratio, with advancing years, no age is exempt from 
it. By reference to the influence of age upon the frequency of true 
primary croup, it will be seen that the maximum of its frequency is 
also attained between the ages of one and five years. We would also 
call attention to the much greater frequency with which diphtheria 
occurs in later life than croup; since of 2136 deaths from croup, but 77 
were over ten years of age ; while of 1804 deaths from diphtheria, not 
less than 199 occurred after that period. Of course it is evident that 
the above statistics not only prove that diphtheria is much more fre- 
quent during the first decade of life than at any subsequent period, but 
also that it is much more fatal then. 

Nature. — In his earliest wi^tings upon this subject, Bretonneau at- 
tached little importance to the constitutional symptoms attending diph- 
theria, and upheld the view that it was essentially a local affection ; 
and though he subsequent!}^ somewhat modified his views, he yet only 
admits that the constitution becomes involved secondaril3^ 

It is indeed true that the epidemics which have occurred during the 
past twenty-five years seem to have been attended by far more grave 
constitutional symptoms than were present in the cases upon which 
Bretonneau's memoir were founded. And at present, it appears to 
us, that a careful study of the very numerous reports of epidemics 
occurring in all parts of Europe, Great Britain, and the United States, 
especially during the past ten years, can leave no doubt upon- the mind 
that diphtheria is a blood disease, attended with marked constitutional 
disturbance, which is usually of a decidedly asthenic character. 

This view is at present almost universally adopted ; and in accord- 
ance with it, we find diphtheria removed from the place which it for- 
merly held in systematic treatises, among the local affections of the 
pharj^nx, and discussed as one of the general diseases. 

The chief arguments in favor of its being a constitutional disease, 
are its epidemic and contagious nature; the continued febrile action, 
of asthenic type, which attends its course; the marked alteration of 
the blood mass in color and consistence; the tendency to pseudo-mem- 
branous exudation on mucous membranes, or abrasions of the skin; 
the occurrence of albuminuria ; and, finally, the frequent development 
of paralytic sequelae, showing the presence of some morbid agent, act- 
ing especially upon the nervous system. 

Bouchut,^ to a certain extent, agrees with Bretonneau. He divides 

1 Mai. des Enfants, 4eme ed., pp. 907-923. 



PATHOLOGICAL ANATOMY. 657 

diphtheria into false, or non-infecting, which is mere pseudo-membra- 
nous angina; and the true, or infecting, which involves the entire 
system, by means of the absorption of septic substances from the 
pharynx. In this respect it resembles pyemia, and produces swelling 
of the lymphatics, alteration of the blood, albuminuria, and even me- 
tastatic deposits. 

Pathological Anatomy. — False Membranes. — We have already dwelt 
npon the fact, that the pseudo-membranous exudation can no longer be 
regarded as the essential and most important element in diphtheria; it 
is, however, one of the most constant and striking phenomena, and in 
certain cases, where it extends into the larynx, becomes the effective 
cause of death. 

It has been most carefully studied in regard to its mode of develop- 
ment and extension, seat, and microscopic characters, by Bmpis, Bre- 
touneau, Wade,^ Thompson, Darrach,^ Trousseau, Sanderson.^ 

Mode of Development. — When fully developed, the pseudo-membranous 
deposit has the ordinary appearances of a fibro-plastic membrane; but 
this stage is preceded, according to the researches of Empis and others, 
by the exudation of a sero-mucous, transparent, and viscid fluid, which 
varies in abundance in different cases, at times even forming, as noticed 
by Trousseau and Empis, in the neighborhood of parts lately covered 
b}' deposit, a sort of submucous exudation, sufficient to raise the epithe- 
lium in the form of phlyctense. 

This sero-mucous liquid does not long remain transparent and difflu- 
ent, but soon becomes a little less transparent in points, gains a yellow- 
ish tint, acquires greater density, and adheres more strongly to the 
subjacent mucous membrane. These points, at first isolated and cir- 
cumscribed, soon coalesce so a& to form a delicate pellicle, but slightly 
cohering, and capable of being raised from the mucous membrane by 
slight traction; although, owing to its friability, it is difficult to raise 
a piece of any considerable size. 

This pellicle is more dense and thick, at its- centre than towards the 
edges, and soon after its formation, the exudation continuing beneath 
it, and coalescing with it, it gains in thickness by the apposition of an 
under layer; until, when the membrane is fully developed, it may con- 
sist of several layers, and appear imbricated. 

At this period its adhesions are so strong that, if it b^e detached from 
its connections, slight hemorrhage will follow, or numerous minute 
bloody points may be seen upon the subjacent mucous membrane. 

According to Empis. the appearance of the opaque spots in the clear 
sero-mucous fluid is due to a precipitation of fibrin independently of 
any agency of living tissue. Thus the tubular casts which form in the 
air-passages are rarely adherent, and are usually much smaller than 
the cavity occupied; and in cases of tracheotomy he has noticed the 



1 London Lancet, February 5, 1859 [et ante). 

2 Trans. ColL of Phys. of Phila., February 6, 1861 (Amer. Jour. Med. Sci.). 

3 Brit, and For. Med.-Chir. Rev., Jan. 1860. 

42 



658 DIPHTHERIA. 

canula to become lined within a few hours with a layer of whitish con- 
cretion, the thickness of which continually increased, and which was 
evidently only the result of coagulation of the liquid by which the sides 
of the canula were constantly covered. 

Color. — The color of the pseudo-membrane varies at different stages, 
and somewhat according to its seat. 

In the fauces, the deposit is often whitish at first, but soon acquires 
a yellow tint; though in some cases it is quite gray, and produces the 
appearance of extensive sloughs on the fauces and pharjmx. In severe 
cases, there is usually a bloody sanious fluid effused which imbues the 
pseudo-membrane, discolors it, and promotes its decomposition, so that 
it forms dark-colored shreddy patches, exhaling a fetid, gangrenous 
odor. 

It is essential to bear in mind that these appearances of the fauces in 
diphtheria are usually due to decomposition of the false membrane 
alone; and that, if this be removed, the mucous membrane will gener- 
ally be found merely raw, excoriated, and oozing blood. 

It is, however, true that in certain epidemics the rule has been for 
serious lesions of the mucous membrane, involving even its entire thick- 
ness, to occur. 

In milder cases, where the disappearance of the false membrane can 
be studied, it is never seen to separate all at once, leaving in its place 
a cicatrized surface, but the pellicle gradually diminishes in thickness 
and extent. When the pseudo-membrane extends into the larynx, it 
is more apt to remain whitish throughout its course there than in the 
fauces. 

Consistence. — The consistence of these deposits varies considerably. 
In cases of ordinary severity, where the symptoms are not of a very 
adynamic type, the pseudo-membrane is often quite firm, tenacious, 
and elastic; while in grave asthenic cases, with severe inflammation of 
the throat, the deposit is apt to be much less firm, or even quite pulta- 
ceous. 

It has been attempted to base upon these conditions and the corre- 
sponding microscopic aj^pearances, a division of diphtheritic pseudo- 
membranes into two classes, answering to the well-known division of 
inflammatory lymph into the fibrinous and the corpuscular. 

Microscopic Anritomy. — There were formerly different views enter- 
tained with regard to the minute anatomy of the pseudo-membranous 
deposits in diphtheria. 

Yogel originally associated with the disease the presence of the 
oidium albicans, the parasite which we have seen to be characteristic of 
muguet; and, more recently, Laycock, of Edinburgh, has insisted upon 
the occurrence of this crj^ptogam in the pseudo-membranes of diph- 
theria. 

Dr. Wade, of Birmingham, has noticed also in some cases, in or near 
the exudation, the spores of the leptothrix buccalis, a fungus very com- 
monly met with in the secretions of the mouth and pharynx. 

Further investigations have shown, however, that these parasites are 
occasionally present in numerous diseased conditions of the mouth and 



MICROSCOPIC ANATOMY AND CHEMICAL CHARACTERS. 659 

fauces, and that their occurrence in diphtheria is to be considered as a 
mere accident, and not as an essential part of the affection. 

The microscopic appearances which are constant, are the ordinary 
elements of corpuscular l^^mph: exudation cells or even pus-corpuscles, 
granule cells and free fatty granules, and more or less abundant and 
closely interlacing fibrillffi, mixed with epithelial cells of various shapes 
and sizes. In the majority of specimens, the corpuscular elements 
greatly predominate, the fibres being few and small-; and indeed it is 
only in the firmer, more tenacious, pseudo-membranes that much true 
fibrillation is noticed. 

Chemical Characters. — The false membranes contract and shrivel when 
treated with alcohol ; mineral acids, such as sulphuric, muriatic, nitric, 
or chromic ; strong solutions of nitrate of silver ; or solutions of the per- 
salts of iron. 

On the other hand, the}" soften more or less quickly when treated 
with alkaline solutions, as of potassa, soda, lime, or ammonia; or of 
chlorate of potash, chlorate of soda, bromide of potassium ; or with 
glycerin and various other agents. Recently, pepsin and lactic acid 
have also been announced as powerful solvents. These various chemical 
properties are constantly turned to account in the treatment of diph- 
theria, in guiding our selection of the most appropriate local applications. 

Condition of the subjacent 3Iucous 3Iembrane. — Even before the appear- 
ance of the slightest exudation, the mucous membrane of the fauces is 
often seen to be red and somewhat swollen. After the pseudo-membrane 
is fully developed, it is of course impossible, without forcibly detaching 
it, to gain any idea of the condition of the mucous membrane beneath, 
and unquestionably ver}^ man}^ of the descriptions given of extensive 
gangrenous ulceration of the fauces and pharynx, have referred merely 
to the changes in the pseudo-membrane due to its decomposition and 
the imbibition of sanious fluid. 

In the vast majority of cases, the subjacent mucous membrane is not 
truly ulcerated, but is merely much congested and swollen, with an ex- 
coriated and roughened appearance from removal of its epithelium, and 
occasionally presents spots of ecchymosis. 

At times it is whitish, opaque, or unnaturally pale ; while in other 
cases it is purplish or otherwise discolored. When the deposit is raised 
up, especially if it be of the firmer variety, it is often seen to be at- 
tached to the surface beneath by numerous small filaments, as though 
processes of the deposit passed into the mucous follicles. 

Although these may be considered as the most usual conditions of 
the mucous membrane, it is undoubtedly true that in some cases exten- 
sive and deep ulceration, and even gangrene occur, exposing the mus- 
cular tissue of the pharynx, or even producing the destruction by 
sloughing of an entire tonsil gland. 

This accident occurs much more frequently in some epidemics than 
others, as may be readily seen by a comj^arison of the accounts given 
by different authors of the anatomical lesions noticed in the epidemics 
they have respectively studied. 



660 DIPHTHE'KIA. 

The submucous tissue is often oedematous, infiltrated with bloody 
serum, or is the seat of an interstitial exudation of lymph. In some 
cases the oesophagus and the muscular tissue around the fauces and 
pharynx are congested and infiltrated. 

When croup ensues, the mucous membrane of the larynx and trachea 
is more or less swollen and congested, and, according to West, presents 
distinct erosion of its surface, with small ulcers about the edges of the 
glottis, in a larger proportion of cases than ulceration is met with in 
the fauces. M. Isambert^ suggested that this condition might serve to 
distinguish diphtheritic from idiopathic croup; but West has met with 
precisely similar ulceration of the mucous membrane of the larynx in 
cases of primary croup, and is disposed to regard its presence or ab- 
sence as^ mainly dependent on the rate of progress of the disease 
towards a fatal termination, .^ 

Seat OF the Exudation.-— The pseudo-membranous deposit is usually 
first seen upon the tonsils and soft palate, and in some cases is limited 
to these parts throughout the whole course of the case. 

Frequently, however, the exudation spreads and coats the pharynx 
more or less extensively, or exttjnds into the posterior nares, or down- 
wards through the larynx into the trachea and bronchi, or more rarely 
into the oesophagus. 

It is rare for any exudation to occur on the mucous membrane lining 
the cheeks, or upon the gums, though according to some authors, as 
Hutchinson^' and Bouchut, ulcerative stomatitis is in reality buccal diph- 
theria. The epiglottis is at times covered with a pseudo-membranous 
deposit, so as to become swollen, rigid, and almost immovable, and 
hence partially obstructing, without being able to protect, the entrance 
into the larynx. 

The tendency for the exudation to exisend into the nasal passages 
varies much in different epidemics, and, when present, almost always 
betokens the great gravity of the case. 

According to Bretonneau, the exudation occasionally begins in the 
nares and extends thence in so insidious a manner as readily to escape 
detection. 

We will discuss more fully the questions relating to the extension of 
the exudation into the larynx under the head of diphtheritic croup. 

The diphtheritic pseudo-membrane is not, however, limited to these 
raucous surfaces, but is occasionally seen, and especially in very severe 
cases, to form upon the mucous membrane of the vulva or of the anus. 

It is, moreover, a most significant fact in regard to this affection, that 
any portion of the external cutaneous surface which has been denuded 
of epidermis, may become the seat of this deposit, and that in some 
cases the pseudo-membranous formation is even limited to the skin, 
constituting the so-called external or cutaneous diphtheria. So far, 

1 Arch. Gen. de Med., March and April, 1857. 

2 Diseases of Children, 4th Am. ed., 1866, p. 356. 

3 Med. Times and Gaz., March 19, 1859. 



MORBID ANATOMY. 661 

however, from the attending constitutional symptoms being less severe 
in the external than in the ordinary form, the tendency to deposit upon 
the cutaneous surface usually presents itself in eases of a typhoid ady- 
namic type. 

It appears, indeed, that this pseudomembrane may occur at any 
point of the body to which the atmospheric air has access; but it has 
never been noticed on parts which are removed from its influence. 

^Notwithstanding these apparently distinctive features of the diph- 
theritic deposit, it is impossible by mere ocular or microscopic examina- 
tion to distinguish it from the pseudo-membranous deposit in cases of 
ordinary scarlatinous angina. 

It is more, therefore, in the peculiar constitutional disturbance that 
we must look for the specific nature of diphtheria, than in the presence 
and characters of the false membranes. 

The Submaxillary Glands are almost always enlarged, though thej^ 
rarely acquire the enormous size and peculiar brawny induration so 
often noticed in scarlatina. It is, moreover, very rare for this condi- 
tion to terminate in suppuration of the gland. 

The Heart has been found, by Hillier,^ in a state of fatty degenera- 
tion in two cases, and by Bristowe (id. loc.) in one; all of which were 
rather chronic. In some instances where symptoms of endocarditis 
were present during life, the auriculo-ventricular valves have been 
found in an incipient stage of inflammation, (Bridger.*) 

Heart-clots of large size and firm consistence, evidently of ante- 
mortem formation, are also found in a certain number of cases where 
death has been preceded by peculiar signs of circulatory embarrassment. 

The Lungs are not rarely found inflamed and consolidated to a greater 
or less extent. In other cases the exudation is found penetrating 
deeply into their structure, filling the smaller bronchial tubes, and the 
lung itself is in parts collapsed or carnified. 

Bouchut speaks of having seen small apoplectiform patches, similar 
to those which precede the so-called metastatic abscesses in pyemia. 

The Kidneys are at times quite healthy; in other cases, however, 
they have been found congested, and the renal epithelium granular and 
detached, so as to distend the tubules, which also contain fibrinous 
casts (inclosing granules of hsematin, blood-corpuscles, or a few altered 
epithelial cells). (Hillier (loc. cit.), Greenhow,^ &c.) 

The g astro-intestinal canal presents no lesions of importance; in a few 
cases enlargement of the solitary glands of the lower part of the ileum 
has been noted. 

Secondary Form. — -When diphtheria appears in the secondary form, 
the mucous membrane is more violently inflamed. It is of a. deep red 
color, rough, and very much thickened and softened. The tonsils are 
large and soft, uneven, and often infiltrated with pus. In addition, the 
mucous membrane is far more frequently and seriously ulcerated in this 

1 Diseases of Children, Am. ed., 1868, p. 154. 

2 Med. Times and Gaz., Jan. 1864, p. 201 ; and Brit. Med. Jour., Oct. 22, 1864. 

3 On Diphtheria, New York, 1861, p. 160. 



662 DIPHTHERIA. 

form than in the primary. False membranes are almost always present, 
generally on different portions of the fauces, and more rarely over their 
whole extent. They are generally rather soft and thin, of a whitish, 
grayish, or yellow color, dispersed in fragments and easily torn. 

The inflamed parts are usually bathed in a purulent fluid. The sub- 
maxillary glands are large, red, and soft; and, in addition, there may 
be found various lesions of other organs, due to the primary disease, in 
the course of which the diphtheritic angina has been developed. 

Symptoms. — Diphtheria presents itself either as a primary or secon- 
dary affection. The symptoms of this latter form are, however, so in- 
volved with the symptoms of the diseases in the course of which it is 
developed, that it seems desirable to consider it in connection with them 
severally. 

The sj^mptoms of primary diphtheria demand much more attention 
at the present day than was accorded to them a few years ago. 

So long as the disease appeared but rarely, and in a sporadic form, it 
seems to have been attended with few grave sym^^toms, save when ex- 
tension of the pseudo-membrane to the larynx gave rise to croup ; but 
since the prevalence of diphtheria in epidemic and endemic forms, the 
type of the disease appears to have changed, and though cases still 
occur with but trifling constitutional disturbance, there are others, and 
not less numerous, which present all the gravest symptoms of blood- 
poisoning. 

In a strictly systematic discussion it might be well to divide diphtheria 
into a mild form, which would include most sporadic cases and many of 
the epidemic ones, and a severe form, under which head would be com- 
prised all cases distinguished by a high degree of constitutional disturb- 
ance. For practical purposes, however, it is sufficient to give a descrip- 
tion of the ordinary course of the disease, dwelling upon some of the 
most important symptoms, and alluding to the chief peculiarities which 
at times present themselves. 

Local Symptoms. — Examination of the Throat. — The onset of diph- 
theria is often very insidious; so that our attention may not be called 
to the throat by any complaint of the patient, even when a considera- 
ble amount of exudation is already present. 

If the throat be examined, however, on the first day of the disease, 
the exudation may often be found even at that time, though it is some- 
times not found before the second day. The fauces generally present 
slight swelling and redness prior to the appearance of the false mem- 
brane, which almost always shows itself first on one of the tonsils only, 
in the form of whitish or opaline spots, like coagulated mucus, which 
soon run together and extend over the whole gland, and then to the 
soft palate and pharj^nx, though it sometimes remains limited to the 
tonsils and soft palate. A little later in the attack the plastic deposit 
exists in the form of layers of greater or less extent ; it has lost its trans- 
parency, become firmer in consistence, thicker, and changes from a 
white to a yellowish-white or lardaceous, and sometimes grayish color. 



LOCAL SYMPTOMS. 663 

The breath in this case is offensive, but not fetid; and there is but 
little salivation. 

When, in favorable eases, the disease is left to pursue its natural 
course, the pseudo-membrane becomes thinner, assumes a grajnsh tint, 
and falls off about the sixth or seventh day. When, on the contrary, 
topical remedies are applied to the throat, the membrane is often de- 
tached after one, two, or three days, but may be reproduced several 
times before the conclusion of the case. 

In some unfavorable cases, on the contrary, even though the exuda- 
tion may disappear more or less completely from the pharynx, it extends 
downwards into the larynx, and we have true croup developed, which 
but too often proves fatal in spite of all remedies. 

In more violent cases, the pseudo-membrane, about the time that it 
begins to be detached, assumes a grayish or blackish color, and hangs 
in shreds from the surfaces to which it w^as attached. The fauces, under 
these circumstances, present a gangrenous aspect, the mucous membrane 
having an appearance as though it were falling off in sloughs; the breath 
is extremely fetid, and there is more or less abundant salivation, or in 
some cases an expuition of sanguinolent fluid. 

There can be no doubt that it w^as from misconception of such cases 
as these, that the titles of gangrenous and putrid sore throat arose. 

As the exudation disappears from the pharynx, the swelling of the 
parts affected gradually subsides. The mucous membrane, from which 
the plastic matter has just fallen, is more or less injected and red ; the 
tonsils and soft palate are sometimes* found to be reduced below^ their 
natural size. 

Even when the throat affection is very severe, there is not often so 
much difiiculty in opening the jaws nor in deglutition as is met with in 
scarlatina. 

The submaxillary glands are almost always enlarged and slightly 
painful to the touch, about three or four days after the appearance of 
the pseudo-membrane. The enlargement is usually greatest on the side 
where the inflammation of the fauces is most intense. The surrounding: 
cellular tissue shares in the inflammation, so that the swelling is often 
very great, and impedes the movements of the jaw; it is rarely, how- 
ever, save in very bad cases, so hard and painful as the corresponding 
swelling in scarlatina. 

Pain and Difficulty in Deglutition. — There is quite frequently no com- 
plaint of pain in the throat, although, even at the outset, swallowing is 
usually somewhat difficult and painful, and pressure behind the angles 
of the jaw causes a moderate degree of suffering. 

As the pseudo-membranous exudation increases, and the submax- 
illary glands become swollen and tender, deglutition becomes more 
difficult and painful, and, at times, attempts to swallow fluids are fol- 
lowed by cough and the return of the fluid through the nostrils. 

In cases where the false membranes decompose and acquire a gan- 
grenous aspect, and typhoid symptoms are present, the pain and diffi^- 
culty in swallowing, if they have existed, are apt to disappear. 



664c DIPHTHERIA. 

Yarieties Depending upon Extension of the Exudation. — 1. 
Groiipal Variety. — It would be a matter of much interest to determine 
in what proportion of cases this complication may be anticipated, and 
whether there be any definite and constant relation between the 
amount or character of the exudation in the pharynx and its extension 
to the larynx. As yet, however, no general conclusions can be arrived 
at in regard to any of these points. The frequency of its occurrence 
varies much in different epidemics, the proportion varying from one 
or two per cent, to as high as fifty per cent, of all the cases. 

As might be expected from the considerations presented under the 
head of croup, this complication occurs more frequently and is much 
more fatal in children than in adults. 

It is a well-recognized fact that true diphtheritic croup is nearly 
always preceded or accompanied by pseudo-membranous exudation in 
the fauces or pharynx, but the amount of deposit in these latter 
places may be extremely small and yet be followed by extensive exu- 
dation in the air-passages; while^ on the other hand, there is often 
copious deposit upon the pharynx in cases where the larynx does not 
become invaded. 

No case, indeed, is free from the chance of this complication; it con- 
stitutes the chief source of danger in the mild variety, and yet is occa- 
sionally met with as the immediate cause of death in the most malig- 
nant attacks. 

The pseudo-membrane is quite frequently found, in cases where the 
air-passages have become involved, to extend through the larynx and 
trachea, as far down as the tertiary bronchi, or in some instances, even 
to their finest divisions. 

In this respect diphtheritic croup does not differ from primary croup, 
unless it be, indeed, that it seems to be more frequent in the former for 
the exudation to extend to the smaller bronchial tubes. 

We have seen that there is no essential difference in the condition of 
the mucous membrane beneath the deposit in the two affections; and 
that they are equally liable to be associated with inflammatory condi- 
tions of the lungs. 

Unless, therefore, the more highly corpuscular character of the ex- 
udation in diphtheria constitutes aground of distinction between these 
two forms of croup, it seems difficult to establish a diagnosis between 
them on merely anatomical grounds. 

When diphtheritic croup is secondary, appearing in the course of 
measles, scarlatina, or other general disorders, the conditions found 
after death in the larynx are much the same as in primary diphtheritic 
croup. The mucous membrane here, however, as in the fauces, is 
usually more intensely inflamed, and is more frequently ulcerated. 

The possibility of the occurrence of croup should never be lost sight 
of, and every case should be treated as though it tended to invade 
the larynx. It is especially important to detect the very earliest signs 
of the approaching danger, since its onset is frequently extremely in- 
sidious. 



SYMPTOMS OF DIPHTHERITIC CROUP. 665 

If violent cough is excited by attempts to swallow liquids, it usually 
indicates that the epiglottis is inflamed, and the seat of pseudo-mem- 
branous exudation, which impedes its movements and thus allows the 
fluid to pass into the larynx. The extension of the exudation to the 
larynx is indicated b}^ the cough acquiring a rough croupy sound, 
though it often has not the loud clangor of ordinary croup; the respira- 
tion becoming ^bilant, and the voice weak and hoarse. 

"When the false membrane in the larj^nx is fully developed, the voice 
is almost or quite extinct, and the cough^ losing its croupy character, 
becomes stifled and less frequent. The respiration is now peculiar; 
there is constantly a certain degree of dyspnoea, as shown by the fre- 
quent labored breathing, but there are, in addition, paroxysms of suf- 
focation, induced by spasm of the laryngeal muscles, during which the 
dyspnoea is frightful, and attended with tossing of the whole body and 
the most violent eff'orts at inspiration. 

Death may occur during one of these paroxysms; but usually they 
subside and are followed bj' intervals of comparative ease, soon inter- 
rupted by the recurrence of the same alarming phenomena. 

The intervals become more and more brief, and finally the patient 
sinks into a comatose condition, and dies with all the symptoms of 
asphyxia. If, during the violent efforts at respiration which attend 
these paroxysms of dyspnoea, or owing to the action of remedies, por- 
tions of the exudation are dislodged and coughed up, the most urgent 
symptoms are often immediately relieved. It is, however, but a de- 
ceitful repose, for in most cases the pseudo-membrane re-forms, and the 
recurrence of the croupy voice and sibilant respiration announce that 
the danger of suffocation is again imminent. 

In favorable cases, however, either when the membrane does not 
re-form, or when it is dislodged as often as formed, recovery may 
occur; the paroxysms of dyspnoea recur at lengthening intervals, 
and finally disappear; the cough becomes gradually more soft, and 
fragments of pseudo-membrane, mixed with muco-purulent fluid, are 
discharged; the voice returns, and the capillary circulation becomes 
re-established. 

In some cases, when the exudation has extended through the larynx 
and trachea deeply into the minute bronchial tubes, there is an ab- 
sence of marked croupal symptoms, and death occurs slowly, after 
extreme dyspnoea and oppression of the chest, with all the symptoms 
of deficient aeration of the blood. These cases occur more frequently" 
in adults than in children on account of the larger size of the larynx 
in the former. 

The reader is referred for a more full account of this condition to the 
article on pseudo-membranous laryngitis. 

2. JVasal Variety. — We have already mentioned that Bretonneau states 
that the disease occasionally begins at the nares, and extends thence in 
a most insidious manner. More frequently, however, the affection of 
the nares is consequent upon an extension of the exudation from the 
pharynx. 



6QQ DIPHTHERIA. 

This complication is second in gravity only to the occurrence of 
croup. It impedes still further the already obstructed respiration, is 
attended with a foul acrid discharge from the nostrils, and, in addition, 
experience has shown that it is usually a sign of great malignancy in 
the case. According to Trousseau, the result is almost always fatal, 
the blood-poisoning being marked, as shown by the great alteration in 
the physical properties of the blood, the proneness to hemorrhages, 
the waxy pallor of the skin, and the ultimate fatal termination by syn- 
cope. 

The detection of this complication in its incipient stage is therefore 
of the highest importance, and Bretonneau (5th memoir, Syd. Soc. 
Trans. ^ p. 196, 197) has laid doAvn the most minute directions for its 
recognition at this stage. If the patient present any evidence of dis- 
ease of these passages, as a slight snuffling or coryza, during the preva- 
lence of diphtheria, the finger should be placed behind the angle of the 
lower jaw, below the lobe of the ear, and thence passed down the side 
of the neck, and if swelling of the cervical glands be noticed, it renders 
it probable that there is false membrane in the nares. 

If, further, the tipper lip be found reddened exclusively under one 
nostril, and that on the side of the glandular swelling, or if the swell- 
ing exists on both sides, but unequally, and if the lip is correspondingly 
reddened, the probability that there is nasal diphtheria is converted 
into a certainty, since ordinary coryza, acting equally on both nostrils, 
produces equal redness of both sides of the upper lip. 

3. Cutaneous Diphtheria. — It is one of the characters of diphtheria 
which entitles it to be regarded as a blood disease, that different and 
distant parts are apt to become affected simultaneously or consecu- 
tively with the peculiar inflammation and exudation. We find, indeed, 
that in many cases of diphtheria there is a tendency to the formation 
of pseudo-membrane u]Don any portion of skin denuded of its epi- 
dermis. 

This tendency varies greatly in different epidemics; according to our 
experience it is of rare occurrence in this city. It was, however, no- 
ticed by Bard nearly a century ago, and has been made the subject of 
special study by Bretonneau and Trousseau.^ The pseudo-membrane 
forms upon any blistered surface; upon leech-bites; upon excoriations; 
in fissures, as behind the ears, or at the angles of the mouth; or on the 
outlets of the vagina and rectum. 

The part that is to be the seat of pseudo-membranous deposit he- 
comes surrounded by an erysipelatous redness; it is painful, exudes an 
abundant fetid serous fluid, and soon becomes covered with a grayish 
false membrane. This deposit gains in thickness from beneath ; and, at 
the same time, extends in every direction, by the develoj^ment of vesi- 
cles in the neighborhood, the bases of which become the seat of diph- 
theritic deposit. 

The layers of membrane, bathed in the fetid serous fluid, soon change 

1 On Cutaneous Diphtheria, Arch. Gen. de Med., 1830 (et loc. ante cit.). 



GENERAL SYMPTOMS. 667 

color, decompose, become horribly offensive, and impart the appear- 
ance of true gangrene. 

Trousseau has observed this cutaneous exudation in cases where no 
affection of the throat existed, and has clearly established the identity 
of these various forms of diphtheria by facts collected in an epidemic 
in the neighborhood of Orleans, where the disease in some persons pre- 
sented its ordinary features, while in others the exudation occurred on 
the vulva, on blistered surfaces, on the hairy scalp affected witli favus, 
or npon ulcers. 

The constitutional symptoms which accompany cutaneous diphtheria 
are usually extremely grave and adynamic. 

General Symptoms. — In the mild form of this disease the invasion 
is often highly insidious ; there is usually fever, but the strength and 
appetite are not much disturbed at first. There is at the same time, 
in some, but not all cases, pain in the throat, which may or may not 
be accompanied by diflSculty of deglutition. Both these symptoms 
are, however, often very slight, or they may be entirely wanting, a 
fact with which the practitioner should be well acquainted, as this 
absence of local symptoms by whfch to explain the cause of the sick- 
ness, gives to the disease, in some instances, a remarkably insidious 
character which may well mislead. In one fatal ease, at three years 
of age, that came under our notice, there were neither complaints of 
pain, nor difficulty of swallowing, so that the parents had not the least 
suspicion of the throat being the seat of disease, though we found it 
violently inflamed, and covered with deposits of thick false membrane 
in points. On another occasion, we were sent for to see two children 
who had been sick for four days with slight fever, languor, and loss of 
appetite, but who were not thought to be seriously ill. We found them 
laboring under extensive pseudo-membranous angina, with the early 
symptoms of croup. They both died a few days later of croup. The 
symptoms, prior to the development of the croup, had been so mild in 
both cases as to cause no alarm, and yet the anginose disease had evi- 
dently been progressing insidiously for several days. We attended, a 
few years since, for three days in succession, a boy who was attacked 
suddenly with vomiting and slight fever, loss of appetite and languor, 
and whom we supposed to be suffering from mere gastric irritation. 
His only local symptom was pain in the chin, and this w^as not reported 
to us until afterwards. The mother chanced to look into his throat, 
and, finding there some whitish spots, sent us word. We found him 
with very considerable membranous exudation, w^hich was fortunately 
prevented from extending into the larynx by proper treatment. Quite 
frequently have we been sent for to see children attacked with croup, 
and on finding the fauces thickly covered with exudation, have been 
told that the patient has been ailing for near a week before with lan- 
guor, slight peevishness, loss of appetite, and some little pain in the 
throat. To this point, the strangely insidious character of the angi- 
nose symptoms in the early stage of many cases, we cannot too strongly 
invite the attention of the reader. It is one of the very greatest im- 



668 DIPHTHERIA. 

portance, since at that time, above all others, ought the case to be 
placed under proper treatment. 

The constitutional s^^mptoms are indeed so trifling in some of these 
cases, that the name diphtheroid sore throat has been applied to them. 

It has been, on the other hand, stated, that, during epidemics of diph- 
theria, cases occur which present the usual general symptoms, with 
some difficulty of swallowing and swelling of the cervical glands, but 
in which no pseudo-membrane is formed, the fauces being merely of a 
dark-red color, with swelling and elongation of the uvula, and some- 
times tumefaction of the tonsils. 

Such cases are rarely fatal, and, as a rule, yield readily to the ordi- 
nar}^ treatment for diphtheria. 

These mild cases, in which the only danger is from the extension of 
the exudation into the larynx, are, however, far from constituting diph- 
theria as it is now known to us ; and there are numerous cases in which 
the gravity depends not upon an accidental extension of inflammation, 
but upon the essential alteration of the blood, and the condition of the 
entire system. 

In these cases also the onset may be insidious, though it is often pre- 
ceded for a short time by general malaise, indisposition to play on the 
part of children, and to exertion on that of adults, and slight swelling 
of the cervical glands, and pain on deglutition. 

"Whether these prodromes have been present or not, a more or less 
marked chill ushers in the febrile action, which is often quite intense 
for a few days ; so that, when the throat affection is decided, a doubt 
may exist for a short time whether the approaching attack is one of 
scarlatina or diphtheria. The fever, however, soon subsides almost 
completely, sometimes indeed leaving the surface pale and cooler than 
natural. The pulse may remain frequent, but is weak and compressible ; 
and the general symptoms are all characteristic of deficient vital force. 

There is not usually any marked mental disturbance after the second 
day, the child being intelligent, though dull and indisposed to pay at- 
tention to anything. 

There are but few symptoms of digestive disorder; the appetite, 
which is often retained for the first day or two, soon diminishes, and 
the child often becomes unwilling to take any food, partly from the 
pain caused by the efforts to swallow, partly from complete anorexia. 
There is rarely any vomiting, unless provoked by remedies ; and the 
bowels, though usually torpid, occasionally incline to be loose. The 
urine is rather scanty, quite frequently albuminous, and upon micro- 
scopic examination is found to contain renal epithelium, and casts from 
the renal tubules. This symptom will be again and more fully alluded 
to among the complications. 

At the same time, the submaxillary glands enlarge, and the fauces 
assume the appearances we have already described. There is a great 
increase in the secretion of saliva, which often dribbles quite profusely 
from the mouth, and is apt to be offensive, though rarely fetid. In 
many cases there is in addition a discharge from the nostril, which be- 



GENERAL SYMPTOMS. 669 

comes acrid and offensive when there are false membranes in the nasal 
passages. 

The voice is commonly obscured and nasal, or somewhat hoarse, 
even when the larynx is not involved. 

Cough sometimes exists, and may have a slightly ringing spasmodic 
character, due to mere irritation of the larynx, though it usually re- 
sembles in sound that produced by the action of hawking, rather than 
a common cough. 

In a very small proportion of the cases, an eruption, resembling that 
of scarlatina, appears at irregular periods in the course of the disease. 
It appears, however, that this eruption lacks the punctated appearance 
of the scarlatinous rash ; does not appear at any fixed day of the dis- 
ease; is irregular in its progress, and is not followed by desquamation. 

The reports of it are, however, scarcely numerous or accurate enough 
to enable us to say positively that intermingled cases of scarlatina have 
not been mistaken for diphtheria, or that the two poisons may not have 
been acting jointly. 

The further course of these cases varies widely. If the result is to 
be unfavorable, the depression and loss of strength increase rapidly; 
the surface grows pale or sallow, and is below the natural temperature; 
the pulse becomes exceedingly frequent and feeble; the fauces assume a 
gangrenous aj^pearance from decomposition of the false membranes ; 
the swelling of the cervical glands increases, and the patient often 
refuses to make the effort to swallow, though deglutition is still gener- 
ally possible ; there is a constant fetid discharge from the mouth and 
nostrils; the breath is horribly offensive ; and death ensues amid the 
most profound prostration. Or, at a much earlier period of the dis- 
ease, the fatal event may be precipitated by the extension of the exu- 
dation to the larynx. 

If, on the other hand, the case tends toward recovery, the false mem- 
branes become detached and thrown off, the strength improves, the 
pulse becomes fuller and stronger, and the appetite returns. Even in 
advanced convalescence, however, there is serious danger, as will be 
seen more fully hereafter, of the occurrence of troublesome or even 
fatal sequelae. 

In a still more severe group of eases than those above sketched, the 
symptoms are of the most asthenic or malignant type. 

In these cases the anginose affection, though it may be severe, rarely 
attracts much attention. The pseudo-membranes in the fauces are soft 
and pulpy, and, when examined microscopically, highly corpuscular 
and granular; they soon decompose, and become discolored by the 
blood which exudes from the mucous membrane. There is, moreover, 
a strong disposition for the exudation to extend to the posterior nares, 
or to appear on various portions of the external cutaneous surface. 
The breath and the discharge from the mouth and nostrils are indescri- 
bably fetid. In some cases true ulceration, and even gangrene, of the 
fauces occurs. There is, however, less pain complained of, and less in- 
disposition to swallow than in many lighter cases, owing probably to 



670 DIPHTHERIA 

the depression of the nervous centres from the poisoned state of the 
blood. There may be high fever during the first few days, but this 
soon disappears, and is replaced by a deadly pallor of surface ; ex- 
tremely feeble, running pulse; and at times low muttering delirium. 

Passive hemorrhages from the nostrils, mouth, rectum, or other mu- 
cous passages, are of frequent occurrence. 

The result in these cases of profound diphtheric infection is almost 
invariably fatal ; death resulting quietly from pure exhaustion, without 
the development of any complications. 

The duration of diphtheria varies considerably. Ordinary cases re- 
cover in about seven, eight, or nine days, whilst more severe attacks 
are often protracted until the end of the second week. 

It is impossible, however, to say that the disease has actually run its 
course in this time, since therB are sequelae which may appear during 
advanced convalescence, and retard the recovery even for many weeks. 

On the other hand, in fatal cases, death may occur from croup as 
early as the end of the second day; though usually the larynx does 
not become implicated under five or six days, and this accident may 
occur so late as the twelfth or fourteenth day of the attack. 

In extremely malignant cases, death may also occur during the first 
few days. On the whole, however, it may be said that the majority of 
deaths from all causes occur in the period between the sixth and 
twelfth days. When death results from one of the sequelae, either dis- 
ease of the kidneys or paralysis, it may be deferred for weeks, or even 
for several months. 

Prognosis. — In cases of ordinary severity, when the patient is seen 
early, and the disease remains limited to the pharynx, the result is 
usually favorable; though no case^ not even the mildest, is free from 
danger, either of extension into the larynx or bronchial tubes, of ex- 
haustion, or of the supervention of some complication, such as endocar- 
ditis, or the formation of heart clots. If, on the contrary, the exuda- 
tion extends to the nasal passages, the prognosis is more unfavorable ; 
and when the larynx becomes implicated, the prognosis is exceedingly 
grave; if the disposition to the production of false membrane spread 
to the skin, rectum, or vulva, the prognosis is also very grave, and 
death generally occurs in a state of profound adynamia. 

If any other signs of unusual malignancy are present, such as abnor- 
mal slowness, or great frequency and smallness of pulse; marked pros- 
tration, with pallor and coolness of the surface; great tumefaction of 
the cervical glands; abundant pseudo-membranes, pultaceous and rap- 
idly decomposing; hemorrhages from various mucous surfaces; acrid, 
fetid discharges from the mouth or nostrils; intense and persisting 
albuminuria, with diminution of the amount of urea excreted; the 
prognosis is, of course, much more unfavorable. 

It must be remembered, however, that no one of these symptoms, 
nor even any combination of them, is necessarily of fatal import; that 
cases are often rescued apparently from inevitably impending death; 
and that, however threatening the symptoms may be, it is our duty, 



DIAGNOSIS. 671 

in this disease even more than in many others, to persevere to the very 
hitest moment in the judicious application of suitable remedies. 

It is as yet impossible to arrive at any plausible estimate of the 
average mortality of diphtheria, so widely does the proportion vary in 
different epidemics. ]^"either sex nor temperament appear to have any 
influence upon the result ; but extreme youth undoubtedly renders the 
jn'ognosis much more grave. 

The prognosis in the secondary form of diphtheria is also more unfa- 
vorable than in the primary. 

Diagnosis. — TVe have already suflSciently dwelt upon the general 
symptoms and local signs which enable us to detect diphtheria, in every 
instance, after the disease has fully developed itself 

In examining the fauces in the early stage of the affection, it is well 
to remember that in simple angina, the crypts of the tonsil-glands occa- 
sionally become so distended by their secretion as to present the ap- 
pearance of small, round, and slightly elevated whitish patches, which 
might readily impose upon a hasty observer for pseudo- membranous 
deposits. 

In regard to the value of the peculiarities upon which a differ- 
ential diagnosis between diphtheritic croup and idiopathic primary 
membranous croup is so frequently based, we have fully expressed our 
opinion in the article on the latter disease, to which we would refer the 
reader. 

Diagnosis from Scarlatiria. — The great resemblance which at times 
exists between the anginose symptoms of scarlatina and diphtheria has 
led some authors to suggest that they are identical diseases, and the 
following further points of resemblance have been adduced : the two 
affections prevail frequently simultaneously in the same region, and 
even in the same family; in certain cases of diphtheria, a rash, very 
similar to that of scarlatina, is said to appear; and the urine, in diph- 
theria, is frequently albuminous. That this similarit}" is, however, 
more apparent than real, is evident from the following considera- 
tions. 

1. Although in some epidemics of diphtheria a rash is said to have 
been occasionally noticed, its occurrence is at most the rare exception, 
instead of the almost invariable rule, as in scarlatina; it differs, too, 
from that of scarlatina, in appearing at irregular periods, in being par- 
tial, appearing suddenly in patches, not deepening gradually in inten- 
sity, and in being of a uniform erythematous redness, without the punc- 
tated appearance peculiar to the scarlatinous eruption. 

2. The albuminuria of diphtheria presents these distinctive features 
as compared with that of scarlatina, that there is not always any dim- 
inution in the amount, nor any constant change in the character of 
the urine when it is present; that it occurs in the early part of the at- 
tack, and increases as the disease approaches its height, or may disap- 
pear suddenly, even in the early part of its course; that although usu- 
ally noticed in severe cases (and probably a very unfavorable symptom), 



672 DIPHTHERIA. 

there seems to be no necessary connection between the urine becoming 
non-albuminous and the disease assuming a milder type. 

3. There is a wide difference in the sequelae which succeed the two 
affections; dropsy scarcely ever following diphtheria, while various 
paralytic phenomena, which are rarely noticed after scarlatina, are of 
frequent occurrence. It is very much more common, also, to have sup- 
puration of the glands of the neck after scarlatina. 

4. In the same way, endocarditis, though it has recently been noticed 
in a few cases of diphtheria, is much more frequent in scarlatina. 

One of the most positive proofs of the essential difference of these 
two affections is the fact, attested by universal experience, that they 
exercise no protective power whatever against each other, and that in- 
dividuals whose systems are protected against a second attack of scar- 
latina, are fully as likely to contract diphtheria as those who have never 
suffered with either of these diseases. 

It may also be added that second attacks of scarlatina are very rare, 
while they seem to be much more common in diphtheria. 

It seems evident to us, therefore, that in the present state of our in- 
formation upon this subject, scarlatina and diphtheria must be regarded 
as entirely distinct affections, although presenting quite numerous points 
of singular resemblance. 

Complications and Sequels. — Albuminuria. — We have already briefly 
alluded to the peculiarities of the albuminuria of diphtheria, but the im- 
portance of the symptom merits a more full discussion. 

The occasional presence of albumen in the urine in cases of diphtheria 
was first noticed by Mr. Wade in 1857, who also found associated with 
the albumen, tube-casts and renal epithelium. It was shortly after- 
wards recognized by MM. Bouchut and EmpisMn thirteen out of fifteen 
cases; and since then has been found, in a varying proportion of the 
cases, by many observers in different epidemics. 

The character of the urine when it contains albumen is not constant, 
but usually it is quite pellucid, of acid reaction, and apparently free from 
any deposit; although, on standing, both tube-casts and epithelium may 
settle to the bottom. The quantity also varies considerably, Hillier 
having found it much diminished, while, according to West and Wade, 
it frequently remains normal. 

The amount of urea excreted is usually increased in diphtheria, and, 
according to Sanderson, the presence of albumen and tube-casts in the 
urine is not necessarily associated with any interference in its elimina- 
tion, but this does not agree with the examinations of others, who have 
found a diminution of the solid excreta when albumen was present. 

The quantity of albumen varies much, being at times a mere trace, 
and again being joresent in large amount. The kinds of tube-casts 
noticed by Wade, and which are the ones usually found, were small, 
waxy casts; casts of a similar size, but granular, probably from com- 

1 De I'Album. dans les Mai. Couenneuses, Compt. Eendus, 1859. 



HEART-CLOT. 673 

mencing disintegration, and ordinary ej)ithelial casts, and fibrinous 
flakes. 

Albuminuria in diphtheria occurs at various stages of the disorder — 
in some cases even during the first few daj'S. It not rarely comes on 
insidiously, and may manifest its presence by no peculiar constitutional 
symptoms. There can be, however, little doubt of the grave import of 
its appearance, though as yet its exact significance has not been accu- 
rately defined. 

It is indeed true, that it has been found in large quantities in cases 
which have preserved a mild character throughout (Sanderson) ; but on 
the other hand, Bouchut and Empis regard it as a highly unfavorable 
sign, coinciding with very great gravity of the disease; and Wade be- 
lieves that the quantity of albumen is usually in direct proportion to the 
retention of effete material, and that indications of impairment of the 
renal function are almost constantly precursors of an unfavorable termi- 
nation. 

Hillier (ojo. cit.') examined 38 very severe cases in regard to this point, 
and found albumen present in 33, 32 of which proved fatal, while of the 
5 free from albuminuria, all recovered. 

The albumen appeared in 1 case on the fourth day, in 3 on the fifth 
day, in 2 on the seventh day, in 5 on the ninth, and in 1 each on the 
thirteenth and nineteenth days. Usually the albumen disappears from 
the urine as the severity of the symptoms diminishes, but Bouchut has 
known it to persist after convalescence, and finally produce, as in Bright's 
disease, anasarca and hydrothorax. 

Heart-clot. — The formation of coagula in the cavities of the heart 
during life has been noticed in many conditions of the system; and this 
terrible, because almost necessarily fatal accident, is now always dreaded 
in the course of several diseases, of which diphtheria is eminently one. 

There have even been epidemics of an unknown nature, but where 
the only discoverable lesion have been enormous fibrinous concretions 
in the heart. Such epidemics have been recorded by Huxham, Chisholm, 
and recently by Armand.^ 

The symptoms mentioned by these authors as significant of this acci- 
dent are, pain at the pit of the stomach ; difficulty in respiration ; ex- 
treme anxiety and restlessness; anxious expression and depression of 
spirits; slight, dry, and rather spasmodic cough; the face being at times 
livid, and the surface dry and inclining to be cool, with coldness of the 
extremities. The pulse was small and irregular, and, in some of 
Armand's cases, an abnormal murmur was detected in the heart; there 
was usually considerable dulness over the cardiac region ; the respira- 
tory murmur remained pure and quite full, and the chest normally 
resonant. 

According to Eobinson, the first observation of sudden death in diph- 
theria from the formation of heart-clot was made by Dr. Werner, of 
Linz, in Austria, in 1842; and the second by Winkler, in 1852. 

1 Des Concretions Fibrineuses et Polypiformes du Cceur, 1857. 

43 



674 DIPHTHERIA. 

In England, Dr. Eicbardson^ appears to have been the first to call 
attention to the difference between these sj^mptoras of embarrassed cir- 
culation and those of obstructed respiration, as met with in diphtheritic 
croup. 

His account of the symptoms of the former condition agrees closely 
with that given above as to the coolness and almost marbly pallor of 
the surface; the moderate lividity of the ftice ; the constant restless- 
ijess and intense anxiety; the feeble, quick and irregular action of the 
heart, with a muffled character of the sounds, and in some cases an 
abnormal murmur. He also calls attention to a peculiar prominence 
of the anterior part of the thorax in very young children, which he 
believes to be strictly diagnostic of fibrinous obstruction. 

In obstruction of respiration, on the other hand, the surface becomes 
livid, the veins turgid, and the muscles are often convulsed; the heart- 
sounds are clear, though feeble, and the breathing is the first to stop 
at death, instead of the circulation, as in the other case. 

In three cases occurring in the practice of one of ourselves,^ in which 
we were able to diagnosticate the condition, death took place on the 
twent^^-first, twentj^-fifth, and twenty-eighth days respectively. In 
each case the local sj- mptoms had given way and almost disappeared, 
and the children seemed to have entered upon convalescence, when 
slight but steadily increasing signs of circulatory embarrassment be- 
came perceptible, and after a few days battling against the constantly 
increasing obstruction, the little patients each died as though worn out 
b}^ the unequal struggle. 

In no case was there any evidence of any other organ being impli- 
cated ; one of the cases was, however, complicated with albuminuria. 

The pulse was not noted to be over one hundred; the cardiac sounds 
were unattended with murmur, but confused, indistinct, and seeming as 
though reduplicated. 

There was no marked paralysis, but in one case partial paralysis, and 
in another marked muscular debility. 

At the autopsy, in each case, the right side of the heart was full oi 
clots, which were either dark-colored, with whitish spots, or yellowish- 
white throughout, quite firm, and adherent to the endocardium, and 
appeared to have been forming for several days. In one case, a clot in 
the left ventricle presented at its lower extremity a broken, irregular, 
uneven, and frayed or granulated appearance, as though the disinte- 
grating process by which thrombi are broken up, had commenced in it. 
In none of the cases were there any evidences of endocarditis. The 
same accident has been observed during the past ten years by Dr. 
Barry,^ Mr. H. Smith,* and Mr. C. E. Thompson,^ and in a valuable 

1 Med. Times and Gaz., March 8, 1856; British Med. Jour., Feb. 16 and April 7, 
1860. 

2 Dr. J. F. Meigs, Am. Jour. Med. Science, April, 1864, vol. xlvii, p. 305. 

3 British Med. Jour., 1858. 

4 Med. Times and Gaz., Dec. 17, 1859. 

5 Med. Times and Gaz., Jan. 7, 1860. 



ENDOCARDITIS — PARALYSIS. 675 

thesis published recently^ by Dr. Beverley Eobinson (now of New York), 
ten cases are fully described, in at least five of which the ante-mortem 
formation of clots occurred. 

The symptoms which he deduces, from a careful analysis of his own 
and the other recorded cases, as indicative of this condition are: cool- 
ness of the extremities, pallor of the face, prostration, anxiety, agita- 
tion, and peculiar intense dyspnoea; associated with a feeble pulse, dull, 
weak, and veiled heart-sounds, and frequently with the signs of emph}^- 
sema of the lungs. 

Most of the cases have occurred in young subjects, and the clot has 
formed late in the course of the disease, or even after convalescence 
has begun. The cause of this deposition of fibrin is not very apparent; 
in our article on this subject, already referred to, it was suggested that 
the coagulation might depend upon some peculiar change in the tissue 
of the endocardium, analogous to that which gives rise to the diph- 
theritic exudation on mucous surfaces. 

'No such alteration has, however, as yet been detected, and Dr. Eich- 
ardson, to whom the profession is so much indebted for his investiga- 
tions upon the coagulation of the blood, attributes it, in this case, to a 
deficiency of the volatile agent w^hich retains the fibrin in solution, 
together with an actual increase in the amount of the fibrin of the 
blood, this combination producing the most favorable condition pos- 
sible for fibrinous deposition. 

Endocarditis. — Although in the above cases no lesion of the endocar- 
dium has been found, Mr. Bridger (loc. cit.) and others have noticed 
inflammation of this membrane quite frequently in diphtheria. It has 
usually appeared late in the course of the disease, and has been attended 
with pain in the prsecordia, frequent pulse, hurried respiration, an anx- 
ious countenance, with in some cases a systolic murmur. In fatal cases, 
there was found a roughened, reddened, thickened appearance of the 
valves, as if due to interstitial deposit. In some cases, also, a granular 
or fatty degeneration of the muscular fibres of the heart has been ob- 
served, as by Bristowe, Hillier, Robinson, and others. 

Paralysis. — One of the most frequent and important, and certainly 
the most peculiar of the sequelae of diphtheria, is the occurrence of 
paralysis. It originally attracted the attention of MM. Trousseau, La- 
segue, and Faure, under the form of difficulty of deglutition, and a nasal 
character of the voice; but since then has been observed in the most 
varied forms and degrees, afi'ecting both general and special sensation 
and the power of motion. In most cases, every trace of the primar^^ 
disease has disappeared before anj^ paralysis is noticed; the patient 
sleeps, eats, and digests well, yet many cases emaciate, and there is 
often marked pallor of the surface. In many instances, also, especially 
in children, there is great irascibility or irritability of temper. 

Most frequently a nasal character of voice and regurgitation of liquids 
through the nose are the first symptoms to call attention to the disease, 

^ De la Thrombose Cardiaque dans la Diphtherie. Paris, 1872. 



676 DIPHTHERIA. 

though these may be preceded by some slight difficulty in articulation, 
or by alteration of the sense of taste at the back of the tongue. On 
examining the fauces the soft palate is found hanging relaxed, and, if 
it be pricked, there is no contraction of it, nor does it give the patient 
pain. 

At times but one side is paralyzed, and the uvula is drawn towards 
the sound side. The affection may extend no further than the fauces, 
and soon disappear; or it may advance, the eye usually becoming next 
affected, following the throat affection, and preceding any paralysis of 
the limbs. The impairment of vision is rarely of long duration, lasting 
from a few days to two months, and is of every grade, from mere in- 
ability to read fine print to perfect blindness. 

Dr. Greenhow has noticed that the pupils become dilated, and act 
sluggishly under the influence of light, for a day or two before the sight 
becomes sensibly impaired, and may remain so for a time after sight 
has been regained. He has also observed that patients who were un- 
able to read with unassisted sight could do so with the aid of convex 
glasses, so that he attributes the impairment of sight to paralysis of 
the ciliary muscle and temporary loss of the adjusting power. 

In addition to this want of accommodation, however, depending on 
paralysis of the ciliary muscle, Bouchut believes that there is in many 
cases, and especially in those who have had albuminuria, a serous infil- 
tration of the fundus of the eye, due to the anaemic condition of the 
blood, and which may impair the nutrition of the optic nerve, and even 
lead to its atrophy. 

The following case, which came under our observation recently, at 
the clinic at the University of Pennsylvania, affords an interesting il- 
lustration of the peculiarities of this form of paralysis. The ophthalmic 
examination was made by Dr. S. D. Eisley, who has kindly placed the 
results at our disposal. 

Case. Emma W., set. 7 years, suffered with an attack of sore throat, the nature of 
which was not recognized by the physician in attendance. It was quite severe, was 
accompanied by marked swelling of the glands at the angles of the jaws, and com- 
pelled her to be confined to bed for a week or ten days. Soon after convalescence be- 
gan, it was noticed that her voice became altered, and that she occasionally regurgi- 
tated fluids that she attempted to swallow. Her general health improved, however, 
and in a few days she returned to school, which she was soon obliged to quit in con- 
sequence of rapidly increasing inability to read, on account of the print seeming 
blurred and " the letters running together." 

Two weeks later, or about five weeks from the time of the first attack, examination 

of the eyes showed the fundus of both eyes entirely healthy. 0. D.,Y =^. Acuteness 
of vision, as determined by Snellen's types, normal, and she can read Jr. No. 14 at 2^^. 

20 

0. S.,Y = £^, and she reads Jr. No. 16 at 2\ 0. D. emmetropic ; O. S. hyperme- 
tropic = -^j. "With glasses -f ^'2 (convex glasses with 12^^ focus) 0. D. reads Jr. No. 
1 at 12^^, O. S. at 14^^. The pupils react promptly to light. 

She was directed to wear 4. yL glasses for near work, and strychnise sulph., gr. J^., 
was ordered four times daily. This was in a few days increased to five times a day, 
and its use was followed by prompt improvement, so that in less than two weeks the 
power of accommodation was entirely restored. 



PARALYSIS. 677 

Deafness may follow this amaurosis ; then the lower limbs become 
affected, the patient becoming paraplegic, and next the upper extremi- 
ties; then the muscles of the alimentary canal and bladder, causing 
impaction of the rectum with fteces and retention of urine, or the 
sphincters of these organs alone may be involved, and lead to involun- 
tary discharges. Finally, the muscles of the trunk, including those of 
respiration, may become paralyzed, and in some very rare cases even 
the muscles of the heart are involved. It is stated that the paralysis 
of the extremities is never strictly unilateral. The paralysis is rarely 
confined to loss of motion, but, in a majority of cases, sensation is 
either much modified or lost; and indeed in some instances there has 
been no loss of motion, the sentient nerves alone being affected. In 
other cases the sensibility has been found exalted, or there has been in 
the same case hypersesthesia in the upper, with anaesthesia in the lower 
extremities. 

The paralysis, whether it be of motion or sensation, is progressive and 
gradual, even in the same set of muscles, and usually involves one limb 
before it extends to other parts. The mind, though often feeble and 
dull, acts correctly in most cases. 

During the continuance of these phenomena, the appetite may remain 
good and digestion easy; but there are often marked evidences of the 
continuance of some morbid action in the economy. The surface is of 
an earthy, sallow hue, calorification is often imperfect, and the circula- 
tion is much depressed, the pulse being small, weak, and much reduced 
in frequency. 

In some cases, indeed, the affection runs on to a fatal issue, usually 
consequent upon a failure of one of the vital functions of circulation or 
respiration. M. Faure has given a vivid picture of these sequelae in 
their worst form, when the patient, paralyzed, indescribably prostrated, 
with imperfect speech and power of deglutition, impaired vision, imbe- 
cility of mind, oedema, and even gangrene of the extremities, finally 
dies in some fainting fit, or passes away almost imperceptibly. 

The result of diphtheritic paralysis is, however, favorable in a large 
majority of cases; thus of 77 cases collected by Dr. Eeynolds, but 9 
were fatal. The duration is, however, more uncertain, varying from 
one or two weeks to several months, the mean duration being about a 
month. 

It is as yet impossible to advance any satisfactory explanation of the 
cause of these grave paralytic sequelse. They occur probably in one- 
fourth of all cases, in greater or less degree, and are noticed with at 
least equal frequency after mild as after severe attacks. 

At first, indeed, the faucial paralysis was attributed to some such 
local cause as inflammation of the sheath of the nerves supplying these 
parts, and Greenhow still contends that the nerve affections bear some 
proportion to the local severity of the attack, the paralysis and anaes- 
thesia being more complete on that side of the fauces which has been 
most severely affected by the primary disease ; but we have been able 
to satisfy ourselves that this does not occur with any uniformity. Char- 



678 DIPHTHERIA. 

cot and Yalpian have, however, demonstrated in a case of paralysis of 
the palate, lesions both of the palatine nerves and muscles. It is diffi- 
cult to determine whether such lesions are of constant occurrence in 
the ordinary cases which rapidly recover. It seems improbable, also, 
that in cases where w-idespread paralytic symptoms are present, which 
subsequently entirely disappear, any serious lesion of the nerve-trunks 
or of the muscles could have existed. 

Nor is the occurrence of albuminuria necessary for the development 
of paralysis, since the urine is often quite normal throughout the en- 
tire course of cases, which are nevertheless followed by marked palsy. 

The most plausible view we can entertain of the nature of these nerve 
affections, is that they are the direct effect of the diphtheritic poison, 
which, while modifying the blood crasis, and so acting on the system 
at large, has an especial tendency to the nervous S3^stem; while at the 
same time, some of the local forms of the paralysis may be associated 
with lesions of the nerves and muscles of the part affected. 

Ataxic Form. — In some cases, which are comparatively rare, the 
nerve affection does not constitute actual paralysis, but takes the form 
of locomotor ataxia. In such cases, the muscular force in the affected 
parts, usually the low^er extremities, is not materially diminished, so 
that the patient can move them forcibly when he is lying down; but 
there is such a degree of inco-ordination in the motions communicated 
to them, that combined movements, even in the supine position, may 
become impossible. It is, however, especially in walking, that this 
loss of co-ordinating powder manifests itself; the gait becomes irregular, 
the patient falls if the eyes are closed, and the case presents all the 
characteristics peculiar to w^ell-marked locomotor ataxia. 

The first instance of this diphtheritic ataxia appears to have been 
observed by Jaccoud^ in 1861 ; it was soon after noticed by Eisenmann f 
and more recently a well-marked case has been reported by Dr. Gray,^ 
in a bo}^ of nine years old, following an apparently mild case of diph- 
theria. It is evident, also, as pointed out by Jaccoud, that a certain 
number of the cases which have been reported under the name of diph- 
theritic paralysis, have in reality been examples of locomotor ataxia, 
the paralysis having been only apparent. This diphtheritic ataxia is 
in all probability due to the same unknown morbid condition or dys- 
crasia, which causes the actual paralytic symptoms which are more 
frequently observed as sequelae of diphtheria. It usually yields to the 
treatment recommended for the latter conditions, though in G-ray's 
case, death occurred, apparentl}^ from rapid loss of nervous power, seven 
weeks after the appearance of the nervous symptoms. 

Treatment. — The treatment may be usefully considered under the 
two heads of local and general. Of late years, the importance of the 
latter has been more and more recognized as supreme, and, indeed, 

1 Les Paraplegies et I'Ataxie du Mouvement, p. 631, Paris, 1864. 

2 Die Bewegungs Ataxie, Wien, 1863. 

3 London Med. Times and Gazette, February 6th, 1869, p. 141. 



LOCAL TREATMENT. 679 

the utility of all local treatment has been questioned on the ground 
that the throat affection is merely a local evidence of the constitu- 
tional disease, and that the disease rarely kills save by involving 
organs beyond the influence of such agents. Still, on the other hand, 
there are eminent authorities, as Trousseau, who assert that topical 
applications are the most successful and important remedies in diph- 
theria. 

The great objects to be held in view in the local treatment, are to 
favor the separation of the pseudo-membranes, and to prevent their ex- 
tension from the fauces into the larynx and nasal passages. 

Local Treatment. — The most important of the local remedies are 
included in the lists of astringents and caustics. 

Of these, nitrate of silver has probably been used more than any 
other substance for many years past, and is highly recommended by 
M3I. Bretonneau. Yalleix, Grisolle, Eilliet and Barthez, Trousseau, 
AYest, and many others. 

It is employed both in solution and substance. The latter form is, 
however, open to the objections, that if the extent of the false mem- 
branes be at all considerable, the solid caustic can seldom be applied to 
more than a small portion of it, and that it is attended with the risk 
of slipping from the porte-caustic into the pharynx, and thence passing 
into the stomach.^ The solution is therefore generally preferred. M. 
Bretonneau advises its employment in the proportion of half an ounce 
of the salt to an ounce and a half of water; and West employs a solu- 
tion of the strength of a drachm to an ounce. 

We have usually made nse ourselves of a solution often or twenty grains 
to the ounce, and have found it abundantly strong. It may be applied 
either by means of a piece of sponge fastened upon a proper handle, 
which is the best method, or a camel's-hair pencil, nearly as large as 
the end of the little finger. The application should be made once, 
twice, or even three times in the course of the twenty-four hours. 

Hj'drochloric acid is also frequently employed, either pure or diluted 
with from one to ten parts of honey; the more dilute forms being used 
in the case of children. 

It possesses the great advantage over the other mineral acids, that 
its caustic action does not extend much from the point of application, 
but is open to the objection of causing a white plastic exudation on any 
part of the mucous surface, not covered with false membrane, with 
which it may come in contact, which may lead the physician into 
error. 

When the limits of the pseudo-membrane can be seen in the pharynx, 
following M. Bretonneau's advice, the acid may be used more concen- 
trated, and the sponge, after being dipped into the acid and squeezed so 



1 Dr. Geddings recommends, when it is desirable to use the solid nitrate, to reduce 
it to powder, and to roll the sponge probang, previously moistened with mucilage of 
gum arable and squeezed, in the powder until a sufficient quantity adheres,, and to 
apply it thus prepared to the diseased parts. 



680 DIPHTHERIA. 

as to be merely moistened, should be carried rapidly into the pharynx, 
and withdrawn after lightly cauterizing the surface. 

When on the contrar}^ the limits of the membrane cannot be seen, 
the acid should be more diluted, and leaving more of it upon the sponge, 
this should be passed down over the epiglottis and then pressed against 
the base of the tongue, by raising strongly the handle to which it is 
tied, in order to express a few drops upon the mucous membrane of the 
larynx. The cauterization is to be performed once or twice a day, ac- 
cording to the necessity of the case. For children under ten years of 
ao;e, the sponge ought to be about half as large as a pigeon's egg. It 
is to be fastened to a piece of flexible whalebone, by making a crucial 
incision into it, introducing into this the end of the whalebone, and 
securing it with good sealing wax, which is not acted upon by the acid 
as any ligature would be. When about to be used, the whalebone is 
warmed and curved into such a shape as will allow it to pass into the 
pharynx without touching the roof of the mouth. M. Yalleix pro- 
poses that the sponge should be fastened to the whalebone with waxed 
thread, and that this should be covered with sealing-wax, to preserve 
it from the action of the acid. This would certainly be safer than the 
mere wax alone. 

Applications of powdered alum, tannic acid, and chlorinated lime, are 
recommended by writers of high authority. In slight cases, in which 
the disease shows but little disposition to extend, such applications may 
answer very well; but when the attack is threatening, and especially 
when the exudation is spreading, we should neglect these minor reme- 
dies, and resort at once either to nitrate of silver, dilute muriatic acid, 
or the tincture of the chloride of iron. If, however, these powders are 
employed, they may be applied by means of a throat brush, or by caus- 
ing a sufficient quantity to adhere to the forefinger of the right hand, 
and conveying it upon this to the diseased surfaces. 

The astringent and caustic preparations of iron have lately been in- 
troduced in the treatment of this affection with much benefit. They 
cause the pseudo-membranes to contract and shrivel, and thus favor 
their separation, while, at the same time, they modify the action of the 
mucous membrane, and also tend, as does the sol. sodse chlor., to cor- 
rect the fetor arising from the putrefaction of the false membranes, and 
to prevent poisoning of the system by absorption. 

The tr. ferri chloridi and the ferri perchloridum are among the best 
preparations, and may be applied, either pure or diluted, several times 
in the course of twenty-four hours. Monsell's salt, in powder, has 
also been highly recommended by Beardsley, of Connecticut, and pos- 
sesses the same mode of action, though somewhat more escharotic. 

Carbolic acid, diluted with glycerin and water, applied by a mop to 
the throat, appears to possess almost equal virtue in causing the sepa- 
ration of the pseudo-membranes, and preventing their re-formation. 

Various applications have also been recommended from the fact that 
they exercise a direct solvent power over the pseudo-membranes, and 
thus promote their removal. Among those which have been thus 



LOCAL TREATMENT. 681 

recommended are solutions of lime, potassa, and soda; solution of chlo- 
rinated lime; of chlorate of potash or soda; of permanganate of potash; 
of bromide of potassium; of pepsin; and of dilute lactic acid. 

Dr. Jacobi {Amer. Jour, of Obsfef., May, 1868, pp. 13-65), has pub- 
lished an analysis of the relative value of these solvent applications. 
According to him, lime-water requires four to ten hours to thoroughly 
liquefy soft dii^htheritic exudation; while for firm pseudo-membranes, it 
requires from thirty to seventy-two hours. Potash and soda, and their 
salts, act more slowly; and the one other application which he recom- 
mends as equally rapid in its action is a solution of bromine gr. j, bro- 
mide of potassium gr. j, in f5vj of water. 

We have carefully tested the latter solutions, as well as those men- 
tioned above, and from the results of repeated tests, have concluded 
that lime-water is the most ^^owerful in its solvent action upon pseudo- 
membranous exudations. We have frequently found, when fragments 
of firm white exudation have been placed in lime-water at a tempera- 
ture even lower than that of the buccal cavity, that the exterior began 
in a very short time (half an hour) to undergo disintegration, and that 
the whole fragment was reduced in a few hours to a granular putri- 
lage. It is, however, undoubtedly true that this effect will be pro- 
duced with very different rapidity upon different specimens of pseudo- 
membrane. 

There is no real difficulty in making use of any of these applications, 
if the children be properly managed. One or two assistants mu^t hold 
the patient in such a way that the head shall be thrown backwards, 
and the hands and feet secured. The physician must depress the tongue 
with the handle of a spoon held in the left hand, while he holds in the 
right the pencil or sponge mop. If the child refuse to open the mouth, 
it can generally be made to do so by holding the nose in order to force it 
to breathe through the mouth. If this fail, all that is necessary is to 
press the handle of the spoon against the teeth, when the patient will 
soon become too much fatigued to offer further resistance. 

Gargles. — When the patient is sufficiently old and intelligent to be 
able to use gargles thoroughly, any of the substances which have been 
recommended as local applications may be thus used, being of course 
largely diluted. Thus tr. ferri chl., hydrochloric acid, sol. sod« chlori- 
natse, in the proportion of fjj or fjij to f^vj, or chlorate of potash in 
strong solution, may be used as gargles with much advantage in some 
cases. 

These solutions may also be very efficiently applied to the throat in 
a finely divided condition, by means of the steam or hand-ball atom- 
izer; a mode of application which is peculiarly useful in cases where the 
pseudo-membrane has extended to the larynx. 

A very convenient and ready application, and one from which we 
have obtained marked advantage in several cases, especially where the 
exudation had extended to the larynx, is by covering the patient's 
head with a sheet, and introducing a vessel containing slaking lime, so 
that the steam may be freely inhaled. It is probable that the chief 



682 DIPHTHERIA. 

benefit is here derived from the warm watery vapor; though a small 
quantity of lime, in the form of impalpable powder, probably gains 
entrance to the fauces and air-passages.^ 

Ice. — In a rather early stage of the disease, if there is much heat and 
engorgement about the throat, cold, wet compresses may afford tempo- 
rary relief; and great benefit is often obtained in cases where there is 
much swelling and inflammation of the fauces and pharynx, by the free 
internal use of ice, allowing the patient to hold small pieces of it almost 
constantly in the mouth. 

Other external applications may also be employed to reduce the 
swelling of the cervical and submaxillary glands, render deglutition 
more easy, and relieve suffering; and, in this way, the persistent use of 
poultices or spongio-piline fomentations are of service. 

It is essential to remember, however, that all blisters or irritating 
applications capable of destroying the epidermis, must be carefully 
avoided, owing to the tendency, already alluded to, of the pseudo-mem- 
branous deposit to occur on such abrasions. 

When the nasal fossae have become implicated from extension of the 
pseudo-membrane, one of the dilute solutions recommended as gargles 
should be injected through the nostrils, or the desired effect may be 
even more thoroughly secured by the use of the same fluid through a 
Thudichum's nasal douche. 

General Treatment. — Whatever differences of opinion may exist in 
regard to the relative merits of the various local applications we have 
enumerated, all high authorities are now agreed as to the general char- 
acter of the constitutional treatment which should be adopted. 

Some years ago, before opportunities had been presented for study- 
ing diphtheria in its epidemic form, as it has since occurred, it was cus- 
tomary to employ moderate depletion early in the attack, if the patient 
was vigorous and strong, and to follow this by the use of mercury and 
antiphlogistics, with a view of subduing the febrile excitement, and 
causing the dissolution and absorption of the pseudo-membrane. 

With the increase of knowledge, however, of the true pathology and 
natural history of the disease, which has been gained of late years, all 
depleting and antiphlogistic plans of treatment have been, by common 

^ Bouchut has lately strenuously advised active cauterization of the fauces, or abla- 
tion of the tonsils, not only for the purpose of removing the exudation which appears 
on them, which he considers the localization of the disease, but also of facilitating 
respiration. 

According to him, the operation of ablation has now been performed fifteen times, 
five by himself, and ten by MM. Domere, Symyan, Speckahn, and Paillot, with suc- 
cessful results in each case, no false membrane reappearing. 

Despite this favorable report, however, the procedure appears to us objectionable, 
regarding, as we do, the importance of the local condition as secondary to that of the 
alteration of the blood. The operation must further cause the greatest alarm and 
most powerful resistance on the part of young children, and it seems highly improb- 
able that a large proportion of cases should be attended with the same fortunate ex- 
emption from a recurrence of pseudo-membranous formation, as occurred in Bouchut's 
cases. 



GENERAL TREATMENT. 688 

consent, abandoned as indefensible either in theory or practice, and all 
efforts are directed to promoting the nutrition of the patient and sup- 
porting the strength of the system, as indicated by the marked ten- 
dency to prostration, the feeble jDulse, and the manifest deterioration 
of the blood. 

It is probable that those cases in which bloodletting and the admin- 
istration of mercurials were adopted with such apparent benefit, were 
either erroneously considered diphtheritic, or that the disease, when 
occurring sporadically, as it formerly did, was of a far more sthenic 
type than it has presented of late years. 

Eegarding diphtheria as a constitutional affection, depending upon a 
peculiar alteration of the blood, w^e must admit that we are in posses- 
sion of no remedy which in any respect merits the name of a specific 
in its treatment. 

Among the best internal remedies, however, are the various prepa- 
rations of chlorine, iron, and bark, which may be given singly, or, pref- 
erably, in combination. 

Thus there are no remedies of more uniform and marked advantage 
than sulphate of quinia and tincture of the chloride of iron, given in 
full doses at short intervals. Hydrochloric acid or chloric ether may 
be added to these tonics, and this combination is strongly recommended 
by West and other high authorities. 

The Sanitary Commission, in London, rej^orted very strongly in favor 
of a mixture containing tincture of the chloride of iron, with chlorate 
of potash, chloric ether, and hydrochloric acid, sweetened with syrup; 
full doses being employed according to the age of the patient, and fre- 
quently repeated. This combination has been, by Gibb, rendered still 
more stimulating by the addition of muriate of ammonia. 

Oil of turpentine has been recommended (Dr. Perrey, Jfe^^. Times and 
Gaz.^ March 5th, 1859) in large doses, both for its stimulating effect, 
and from its tendenc}^ to promote the absorption of lymph in adynamic 
states of the system, where mercury cannot be given. 

Chlorate of potash, given in Huxham's tincture of bark, has been 
vaunted as almost specific in the treatment of diphtheria; but, as re- 
marked hy West, it unquestionably fails to produce here those excel- 
lent effects which are obtained from its use in ulcerative stomatitis. 

Permanganate of potash, which has been so extensively used of late 
years in zymotic diseases, has been used both locally and internally in 
this affection, but apparently without any very positive advantage. 

Emetics ; Purgatives. — Emetics are useful when the exudation shows 
a disposition to extend to the larynx, or when there is much difficulty 
of breathing from tumefaction of the fauces, or from accumulation of 
the pseudo-membranous deposits. We would recommend under these 
circumstances the use of alum or ipecacuanha, as recommended in the 
article on pseudo-membranous laryngitis; the emetic being repeated in 
six or twelve hours, if the same indication should continue or recur. 

A purgative dose is useful at the commencement of the disease. 



684 DIPHTHERIA. 

merely as an evacuant. After that period only such laxatives need to 
be employed as may suffice to keep the bowels soluble. 

Stimulants. — In the milder forms of diphtheria, where no complica- 
tions exist, the cases usually terminate favorably without the use of 
any stimulants; but there are many cases, on the other hand, charac- 
terized by pallor of surface, marked weakness of the circulation and 
tendency to prostration, great enlargement of the cervical glands and 
extensive disease of the throat, where the pseudo-membranes rapidly 
decompose and assume a gangrenous appearance, and the urine is fre- 
quently albuminous^ in which stimulants^ freely administered, are posi- 
tively required. 

In cases where such adynamic symptoms are present, we should 
begin early in the attack with the administration Of the weaker stim- 
uli, and employ the stronger forms as the disease advances and the 
strength of the system succumbs more and more. 

Food. — In no disease should more sedulous care be paid to securing 
to the patient a proper amount of suitable nourishment; and, indeed, 
in the absence of any remedy which can be looked upon as essential or 
specific, we must assign, perhaps, the most important part in the treat- 
ment of diphtheria to food and stimulants. It is at least certain that 
where these cannot be administered in proper quantity, all other treat- 
ment is unavailing, and hence it is our duty, upon finding that the pain 
and fatigue experienced by the child when forced to take frequent doses 
of medicine make it utterly unwilling to take food, to abandon all 
strictly medicinal treatment, and trust to sustaining the powers of the 
system by the free use of stimulants and concentrated food. 

In cases where mechanical obstruction exists, or where all efforts at 
voluntary deglutition are obstinately resisted from fear of the great 
pain caused by the act, nutritious and stimulating enemata must be 
immediately resorted to. These may consist of beef tea, eggs beaten 
up in milk, brandy in the form of milk-punch, and, further, may be 
medicated by the addition of quinia. They should be given ever}^ three 
or four hours, in rather small quantity, and not so concentrated as to 
irritate the bowel. When thus administered it is quite possible to sus- 
tain life for several days, until food can again be introduced into the 
stomach. 

In addition to the local and general treatment above recommended, 
the patient should be rigorousl}' confined to bed during the whole treat- 
ment, and for at least ten days after the disappearance of the exudation. 
This caution is given, not only on account of the danger of that most 
fatal accident, the formation of a heart-clot, but because we have twice 
known the exudation to reappear when the patient had been allowed to 
leave the bed at too early a period; and in one of these the exudation 
extended into the larynx on the occasion of the second attack, in spite 
of all that could be done, and life w^as saved only by the oj)eration of 
tracheotomy. 

The most scrupulous cleanliness of the person and surroundings of 
the patient should be preserved ; free and uninterrupted ventilation 



MUMPS. 685 

secured; and on account of the positive, though perhaps slight, conta- 
giousness of diphtheria, it is wise to practise separation of the well chil- 
dren in the family from the sick. 

The treatment required in those cases where the pseudo-membrane 
extends into the larynx, and especially the discussion of the indications 
for the operation of tracheotomy, will be found in detail in the article 
on pseudo-membranous lar^^ngitis. 

Treatment of Paralysis. — We have already stated that the prognosis 
in diphtheritic paralysis is usually favorable, the symptoms often dis- 
appearing in the course of time without treatment. The cure may, 
however, be much hastened by a persistence in the administration of 
iron and quinia, to which strychnia may advantageously be added. 

titrate of silver has also been emploj'ed in full doses with apparent 
benefit. 

The j^aralyzed muscles should be faradized daily; and, when acces- 
sible, sea-bathing or sulphur baths may be emploj^ed with advan- 
tage. 

In those cases where the muscles of deglutition are especially af- 
fected, and the nutrition of the patient is suffering from his inability to 
swallow sufficient food, it is desirable to resort to the use of nutritious 
enemata. 

Treatment of Heart-Clots. — Under the supposition that the blood is 
hyperinotic in the latter stage of diphtheria, the various salines, especi- 
ally the vegetable ones, such as the citrates and acetates, and ammonia, 
given either as the carbonate or in the liquid form, have been recom- 
mended by Eichardson. 

When, however, the symptoms indicate that deposition of fibrin has 
absolutely occurred, it is probable that nothing can be done in the 
way of curative treatment. Alkalies may be given internally, the 
vapor of ammonia inhaled, alkaline solutions injected into the veins, 
but there is little reason to hope that any effect upon the clot can be 
produced. 

In one of the cases reported by us (loc. cit.), the clot presented at 
one extremity a granular, partially disintegrated condition, as though 
its removal had begun by interstitial action, and the mechanical effects 
of the blood current; and it is possible that by supporting the powers 
of nature the removal of the clot might be effected in this way. Indeed, 
there are cases on record (quoted by Eobinson, loc. cit.) in which the 
symptoms have most clearly demonstrated the existence of a clot in 
the cavities of the heart, where still recovery has occurred. 



AETICLE III. 



MUMPS. 



Definition ; Synonyms; Frequency. — Mumps is an acute febrile spe- 
cific disease, contagious and epidemic; occurring but once in an indl- 



686 MUMPS. 

vidiial; attended by an inflammation of the parotid and sometimes of 
the submaxillary glands, with a tendency to metastasis to the testicles 
in males and to the mammse, vulva or ovaries in females; and almost 
invariably resulting in recovery. 

Some authors, as Niemeyer, object to classifying mumps with con- 
stitutional diseases ; but the fact that it undoubtedly possesses the fea- 
tures enumerated in the above definition, and which, in the present 
state of our knowledge, must be regarded as specifically characteristic 
of that class of affections, seem to us to fully entitle it to be included 
with the other general diseases. 

Mumps is known under a variety of names in every language. The 
terms usually employed to designate it by English and American 
authors are cynanche parotidea, parotitis^ parotiditis, and inflammation 
of the parotid. 

It will be impossible to obtain any definite idea as to the frequency 
of this affection, until the system has been introduced of registering 
not merely deaths but all cases of disease, since mumps is scarcely ever 
fatal. Its frequency is, however, known to vary very widely in differ- 
ent years, owing to epidemic influences; so that while in certain years 
we do not meet with a single case, in others we are called to a consider- 
able number. 

Causes. — Nothing is known in regard'to the essential nature of the 
cause of mumps. The disease is, however, unquestionably contagious, 
and it quite rarely happens that one member of a family sickens with 
mumps, without some of the other children being attacked. 

Mumps rarely occurs as a sporadic afi'ection, but appears, as already 
stated, in epidemics of varying extent and severity, at times being 
limited to a single locality or even a single institution, and at others 
affecting large cities or districts. 

Season appears to exert a powerful influence upon the development 
and activity of the specific poison of mumps, since the epidemics occur 
nearly always in the spring or autumn. According to Yogel, it is said 
to be endemic on the damp coasts of Holland, England, and France. 

Age also exerts an unquestionable influence, by modifying the suscep- 
tibility to the contagion of mumps. Thus the disease is far most com- 
mon between the ages of seven and fifteen years; whilst it is almost 
unknown before the end of the first year, comparatively rare between 
the ages of one and five years, and, on the other hand^ quite rare in 
adults. 

Although it appearg certain, however, that the susceptibility to the 
contagion of mumps diminishes with each succeeding year after the age 
of fifteen, we must in great part explain the rarity of the disease in 
adult life, by the fact that a large proportion of people have had it in 
childhood, and are thus protected against a second attack. 

Second attacks of mumps are indeed of extreme rarity. 

Anatomical Appearances. — Opportunities yqyj rarely occur for the 
examination of the parotid glands in mumps, since this disease is scarcely 



SYMPTOMS. 687 

ever fatal. Yirehow,^ who has shown that, in cases of symptomatic sec- 
ondary parotitis, the affection starts in the gland-ducts, maintains that 
the idiopathic form occupies the same seat. Bamberger,^ on the other 
hand, states that the whole gland appears enlarged and reddened, with 
its tissues swollen and flaccid, owing to an interstitial exudation of 
Ivmph. The softness and indolent character of the swelHng, however, 
the fact that it usually extends beyond the borders of the gland, and 
its usually rapid and complete subsidence, all induce us to believe rather 
that there is slight catarrh of the ducts, with mere oedema of the inter- 
stitial and surrounding connective tissue. 

It is only in rare and very severe cases that there is sufficient lymph 
effused to undergo organization and lead to persistent increase in the 
size of the gland, or to so compress the ducts as to induce atrophy of 
the true gland tissue. In even more rare cases, it is said that suppura- 
tion may occur. 

Symptoms. — In some cases the attack of mumps is preceded for a day 
or two by slight prodromes, consisting of restlessness, feverishness, loss 
of appetite or vomiting; in excitable children, symptoms of nervous dis- 
turbance may occur. More frequently, however, the local symptoms 
appear simultaneously with the fever, and we have generally found 
positive swelling of the parotid gland upon our first visit to the child. 

The earliest local symptom is often pain, complained of under the ear, 
and increased by pressure and by all movements of the jaw, as in mas- 
tication. There is also stiffness felt in opening the mouth. The swell- 
ing appears first immediately beneath the ear; the depression between 
the mastoid process and the ramus of the jaw quickly becomes filled, 
and the swelling rapidly extends on to the cheek and neck. At first 
the swelling is flat, indurated, and presents the outlines of the parotid 
gland; but it soon becomes prominent, the most marked projection 
usuall}^ being observed immediately anterior to the lobe of the ear, and 
extends beyond the limits of the affected gland. The central part of 
the swelling corresponding to the parotid, remains firm, indurated, and 
more or less elastic, while at the periphery it is softer and often pits on 
pressure. The degree of enlargement varies much in different cases, 
being at times moderate and confined to the parotid region, while in 
other cases, it extends over a large part of the neck and face, and may 
be so great as, especially when both glands are affected simultaneously, 
to give to the head and neck a pyramidal shape. 

Quite frequently the submaxillary glands are involved, and the swell- 
ing consequently extends along the base of the jaw; in more rare cases, 
the enlargement is most marked in this region, or, indeed, the sub- 
maxillary glands may be almost exclusively the seat of the affection. 

The skin over the seat of enlargement is at times scarcely altered in 
color, or may present more or less marked redness. There is usually 
only very moderate tenderness on pressure. The pain suffered during 
the attack varies greatly; in some cases it is merely a marked sense of 

1 Quoted by Niemeyer (op. cit., vol. i, p. 436). 

2 Quoted by Yogel (op. cit., p. 113). 



688 MUMPS. 

tension and pressure, while in other instances, it has been complained 
of as constant and severe, and extending even to the chest and shoulders. 
The movements of the head are impaired, and those of the jaw are im- 
peded to such an extent that the mouth can only be slightly opened, 
and mastication is performed imperfectly and with great difficulty. 

"Usually the swelling increases for from three to five days, remains at 
its acme for a day or two, and then rapidly subsides, so that in about 
ten days the face has regained its natural appearance. 

Mumps usually involves both parotids, though they rarely become 
affected simultaneously; the left gland is said to be most frequently the 
first inflamed, and subsequently, in twenty -four or forty-eight hours, or 
even when the swelling has disappeared from the side first affected, the 
opposite gland becomes enlarged. Occasionally the enlargement does 
not undergo complete resolution, and a circumscribed, painless, hard 
swelling remains for a variable time in the parotid region. In very 
rare cases, suppuration is said to have occurred. The salivary secre- 
tion is variously affected, and may be either diminished or excessive, 
or remain unaltered. Occasionally the external swelling is associated 
with enlargement of the tonsils and cedema of the submucous tissue of 
the pharynx. In such cases the difficulty of deglutition is much in- 
creased, and there may even be marked obstruction to respiration. 

General Symptoms. — Usually the constitutional disturbance in mumps 
is but slight and subsides even before the swelling of the parotid gland. 
Until the disease reaches its height, however, there is fever, with heat 
and dryness of the skin ; the pulse and respiration are accelerated^ the 
appetite impaired or lost, and the thirst usually extreme. There may 
also be, especially in nervous children, marked restlessness, sleepless- 
ness from the pain and discomfort caused by the great swelling of the 
neck and face, and even mild delirium at night. As already mentioned, 
however, these febrile symptoms usually disappear about the fifth or 
sixth day. 

One of the most curious features in parotitis is the tendency which 
occasionally exhibits itself to metastasis. The parts which are liable 
to be thus secondarily inflamed are the testicles and scrotum in males, 
and the mammae, the vulva, and the ovaries in females. The most fre- 
quent of these metastatic inflammations in mumps is the affection of the 
testicle, which is much more common in men than in boys, is usually 
seated upon the same side with the enlarged parotid, and is attended 
with enlargement of the body of the testicle, serous effusion into the 
tunica vaginalis, and oedematous swelling of the scrotum. The swell- 
ing of the parotid ordinarily subsides when any of these metastatic 
affections apj)ear; but occasionally the two inflammations continue to- 
gether, a circumstance which shows, as ^iemeyer points out, that they 
are in reality due to a common cause, and that no true transference of 
inflammation takes place from one point to the other. In some in- 
stances, the swelling of the parotid subsides a variable time before the 
development of the metastatic affection, and, during the interval, 
alarming symptoms of depression and cerebral disturbance have been 



TREATMENT. 689 

noticed, and at times referred to a metastasis to the membranes of the 
brain. There is, however, no actual meningitis present, and upon the 
redevelopment of the external swelling, these nervous symptoms dis- 
appear. 

Prognosis; Duration; Coi.rse; Termination. — Idiopathic paroti- 
tis or mumps almost invariably terminates favorabl3^ The duration of 
the case varies from four or five days in ver}- mild cases, to ten or 
twelve in severe ones. As already stated, the inflammation usually ter- 
minates in complete and rapid resolution. In some cases, however, a 
larger amount of lymph is formed in the interstitial tissue of the gland, 
undei'goes partial organization, and causes a hard, painless s^velling, 
which persists for some time. In some epidemics, suppurative degen- 
eration of the gland has been noticed, and the abscess which formed 
has either opened outwardly or into the external auditory meatus. 

Diagnosis. — The acute febrile character of the affection, and the pe- 
culiar seat and shape of the swelling, always serve to render the disease 
readily recognizable. 

Treatment. — As mumps almost invariably runs a favorable course, 
the treatment should be of a mild and expectant character. 

The child should be strictly confined to bed; the diet should be fluid, 
partly on account of the great difiicultyin mastication, light and diges- 
tible, consisting chiefly of preparations of milk and light animal broths. 
The only internal remedies required are febrifuges, such as spirit of 
nitrous ether and solution of acetate of ammonia, with a free supply of 
water and acidulated drinks; occasional laxatives; and, if there is 
sleeplessness, small doses of Dover's powder or some other anodyne. 

Local applications appear to have little or no influence upon the 
course of the swelling. The only ones to be recommended are warm, 
light poultices, or light water-dressings, covered with oiled silk, which 
do not annoy the child, and tend to favor resolution. If the induration 
be marked and extensive, so as to threaten suppuration, it has been 
advised to apply a few leeches behind the angle of the jaw. If it 
should become evident that suppuration has occurred, the abscess 
should be opened immediately, and the discharge favored by the ap- 
plication of poultices, in order to prevent further destruction of the 
gland or perforation of the external auditory meatus. In cases where 
induration and enlargement of the gland persist, absorbent applica- 
tions, such as inunctions of iodine or mercury, should be made over the 
tumor. 

In cases where alarming symptoms of depression and cerebral dis- 
turbance make their appearance after the sudden subsidence of the 
parotid swelling, the effort may be made to redevelop the external in- 
flammation by stimulating applications to the surface, and by the inter- 
nal administration of nervous and diffusible stimulants, such as ammo- 
nia, musk, or brandy. 

After the acute symptoms of the attack have subsided, and the child 
has fully entered upon convalescence, we would caution against allow- 
ing it to leave bed too soon, since we have occasionally observed such 

44 



690 MALARIAL FEVER. 

premature exposure to be followed by marked febrile sequelae. Thus 
in one case, occurring in an adult, there was marked fever lasting for a 
week; in another case, in a child, there was high fever for ten days; 
and in a third case, also in a child, there was most obstinate and vio- 
lent vomiting for four days ; so violent, indeed, that we feared lest some 
renal complication might have been developed; on examination, how- 
ever, the urine was found to be entirely normal. 



ARTICLE lY. 



MALARIAL FEVER. 



The propriety of introducing a chapter upon malarial fever in the 
present work, is shown not only by the fact that malarial disease is 
extremely frequent in children, but also because it presents, as it occurs 
in them, so many peculiarities as to frequently lead to the true nature 
of such attacks being overlooked. 

Causes ; Frequency. — There are cases upon record in which malarial 
disease appears to have been contracted in utero, and w^here immedi- 
ately after the birth of the infant it has presented unmistakable evi- 
dences of the disease. We have ourselves met with several such cases, 
Avhere the symptoms, and the prompt effect of quinine, left no doubt as 
to the diagnosis. At all periods of childhood, even from the age of a 
few weeks upwards, there can be no doubt that children readily con- 
tract malarial disease on exposure to its cause. Indeed we have met 
with cases which have shown that the susceptibility of children to 
malarial poison may be even greater than that of their parents or 
other adults exposed to the same influences. In children over five or 
six years old the symptoms of malarial fevers are apt to be almost the 
same as in adults: the following remarks must therefore be understood 
to apply especially to those diseases as they present themselves in 
younger subjects. 

Symptoms. — Malaria presents itself in children both in acute and 
chronic forms. The former occurs both as intermittent and remittent 
fever. In our article upon typhoid fever w^e have carefully pointed out 
the fact that in children the febrile movement in this latter disease 
often presents such marked remissions as to have led many authors to 
confound it with malarial disease, under the name of "Infantile Re- 
mittent Fever." But apart from this, true malarial remittent fever 
occurs in children, and indeed it is a peculiarity of all forms of malarial 
disease in early life to present a less marked development both of the 
paroxysms and of the intermissions. Intermittent fever in children 
may occur in any of the forms met with in adults, still the quotidian is I 
by far the most frequent, the tertian less common, and the quartan de- 
cidedly rare. Whichever form may be present, is apt to present several! 



SYMPTOMS. 691 

peculiarities. In the first place, the features of the paroxysms are apt to 
be imperfectly developed. This is particularly true of the cold stage. It 
is ver}' rarely present as a well-developed chill; in some cases, it seems 
to be entirely absent, but usually can be detected by careful observa- 
tion. The child may merelj- become pale, seem weaker and more lan- 
guid, or with this there may be distinct coolness of the hands and 
feet^ and blueness of the nails : less fVequently is there any discernible 
rigor, and as before stated a fully developed chill is very rare. The 
cold stage is of short duration, lasting from a few minutes to a quarter 
of an hour. It is followed by the hot stage, or in some cases the be- 
ginning of the attack is marked by the appearance of fever. The 
degree of this is rarely very high. Sometimes the child, who has been 
merely drooping during the earlier part of the day, is noticed to grow 
more dull, to wish to be constantly in bed, or on the lap, and its head 
and hands grow warm, with perhaps some flushing of the cheeks. In- 
deed, in some cases, the fever is so slight as to pass unnoticed, unless 
the attention of the nurse is directed to it by the physician. In other 
cases the accession of fever is more marked; the skin becomes very 
hot, and the cheeks brightly flushed; the child is dull and yet restless; 
there is rapid breathing, and marked acceleration of pulse. In some 
children, the fever is attended with delirium, and it is not a very rare 
thing to have it ushered in by a convulsion. The fever lasts a very vari- 
able time, and rarely terminates abruptly, as in the case of adults by a 
sudden defervescence with profuse sweating. Indeed, in many cases, 
the child seems somewhat feverish during the entire twenty-four hours, 
but on careful observation is found to present increase of heat at some 
period of the day, and this is often preceded or followed by a short 
period, during which the child is pale and languid, with cool moist brow 
and hands. Added to this irregularity in the symptoms and duration 
of the paroxysms^ is the further source of difficulty, that the accession 
of fever occurs at very irregular hours. In children of even five years 
of age, it may occur at the ordinary time towards noon, but in younger 
children it ma}^ appear much later in the day, or even, as we have sev- 
eral times seen, late in the night. 

There are a few other symptoms to be mentioned in connection with 
the paroxysms. We have already alluded to the occurrence of convul- 
sions ushering in the hot stage. Frequently the child will vomit what- 
ever food was in the stomach at the time of the attack. The urine 
that is passed during the paroxysm is scanty and high-colored, while 
not long after the subsidence of the fever, there is apt to be a quite 
free discharge of limpid urine. Between the paroxysms, if no com- 
plication exists, the child may appear merely listless, with scanty appe- 
tite. Quite frequently, however, the disease is attended with some 
more marked disturbance, either of respiration or digestion. The com- 
plications which we have ourselves most frequently observed, have been 
bronchitis and pneumonia. In cases where the latter has been present, 
the seat of the inflammation has occasionally been the apex of the lung. 

The chronic form of malaria reveals itself in children in the same 



692 MALARIAL FEVER. 

way as in adults. No well-marked paroxysms may occur, but the pa- 
tient has a sallow, cachectic, or anaemic appearance, which of itself is 
quite characteristic. There is more or less emaciation from interfer- 
ence with nutrition, as the appetite is poor or capricious, and the action 
of the liver and bowels sluggish and insufficient. Enlargement of the 
spleen frequently follows, and we have met with well-marked examples 
of ague-cake in very young children. The blood becomes very poor 
and watery, and this, added to the obstruction to the circulation through 
the liver and spleen, in advanced cases may lead to ascites or oedema. 
We are not aware that the marked development of pigment-granules 
in the blood, which has been so often observed in the adult, has yet 
been detected in children suffering with chronic malaria. In some 
very severe and protracted cases, granular degeneration of the kidneys 
with albuminuria, and finally uraemia, has seemed to follow in quite 
young children. Some of the manifestations of malaria which are 
quite common in the adult, are very rare in children. This applies 
especially to the various forms of neuralgia, which, as met with in the 
adult, are so frequently of malarial origin, while we do not remember 
to have met with a single case of this character occurring in children. 

Diagnosis It is our belief that malarial disease in children is often 

not recognized, and that this is due, not so much to its real difficulty 
of detection, as to the fact that the frequent occurrence of the different 
forms of malaria in young children, is not sufficiently borne in mind. 
Undoubtedly also there are difficulties in its diagnosis, which do not 
usually exist in adults. These arise, as before said, from the irregularity 
and imperfect development of the parox^^sms. Our own experience 
has taught us in all cases of irregular febrile action, especially when 
occurring during the spring or fall, without any discoverable lesion to 
account for it, to suspect the malarial character of the attack. So, too, 
in cases where some slight lesion or disturbance of function exists, and 
3^et the child seems too seriously and too obstinately ill for the apparent 
cause, and presents irregular fever with considerable fluctuations, the 
idea of the malarial nature of the attack should always be entertained. 
In some such cases, where it is impossible to reach a definite decision 
from a study of the symptoms, the diagnosis may be made by the ther- 
apeutic test of administering full doses of quinia for several days in 
succession. 

Prognosis. — The result of malarial fever is usually quite as favorable 
in children as in adults, when uncomplicated with any serious local in- 
flammation. All of its forms usually yield readily to specific treatment. 
The chief source of danger lies in the tendency to severe bronchitis 
or pneumonia. In protracted chronic malaria, the anaemic and cachectic 
symptoms have seemed to us to yield to treatment even more raj^idly 
than in the case of adults. 

Treatment. — Children, even at a very early age, bear full doses of 
quinia very well. The amount which we have usually found necessary 
to arrest an attack of intermittent fever is three grains daily for chil- 
dren of one year of age or under, and one grain additional for each 



TREATMENT. 693 

succeeding year, though we have given as much as five grains by the 
mouth in the course of the day to children often months, and without 
the slightest ill effect. It maj^ be administered in the form of powders 
containing one-half grain, mixed with an equal amount of sugar and 
powdered extract of liquorice, repeated as necessary, aiul given at such 
times as to bring the system thoroughly under the influence of the 
drug before the hour at which the accession of fever has been noticed. 
Some children, however^ will not take the powders without difficulty or 
nausea, and the quinia may then be given merely suspended in syrup 
of red orange, or in the following combination : 

]^. — Quiniffi Snlph., • gr. xxiv. 

Acid. Siilph. Diluti, ...... gtt. xxx. 

Syr. Zingiberis, Syr. Simplicis, Aqucie, aa . f^j. 

Ft. sol. — Dose, a teaspoonful three or four times a day, according to age. 

If, however, the stomach rejects it in all of these forms, as we have 
known it to do, we have found the administration by enema of two 
grains of quinia in a tablespoonful of starch-water, three times a day, 
equally successful. 

In ordinary acute cases no other treatment is really required. It 
may be well to give a few doses of some saline febrifuge during each 
day, until the fever is entirely subdued, and of course any special dis- 
turbance of function must be relieved by appropriate remedies. The 
treatment of pulmonary complications must be subordinate to that of 
the general disease. All depleting or perturbing treatment must be 
avoided, and it will generally be found that with the aid of mild coun- 
ter-irritation, the local symptoms will begin to improve, after the 
malarial fever has been subdued by quinia. It is necessary to keep up 
the action of quinia for some time after the paroxysms are broken, be- 
cause the tendency of the disease to recur is fully as great in children 
as in adults. We are in the habit of thus continuing it for three or 
four weeks in diminished doses, giving, however, on each septennary 
period, dating from the arrest of the paroxysms, the full antiperiodic 
dose, suited to the age of the patient. At the same time the child 
should take suitable doses of iron and arsenic, which may be conveni- 
ently given in the following form : 

R. — Ijiq. Potassse Arsenitis, .... f^j. 

Yini Ferri Amari, f^iij- — M. 

Dose. — From a half to a whole teaspoonful thrice daily in water after meals. 

In chronic malaria we must persist in the use of quinia, iron, and 
arsenic, for a considerable period. At the same time careful attention 
must be paid to securing the best possible hygienic influences for the 
child. When practicable, a change of climate should be secured by a 
journey to the mountains or to the sea-shore. The patient should be 
wartnly dressed, and carefully guarded against all exposure to damp or 
cold. The diet should be carefully selected, and everj^ error of diges- 
tion promptly corrected. Even after the child is apparently restored 



694 



SCARLET FEVER OR SCARLATINA. 



to healthy it should not be allowed to return to the locality where it 
contracted the disease, and for several successive springs and autumns 
should take a short course of quinia and arsenic. 



EEUPTIYE FEYEES. 



We shall describe in this eruptive. group of General Diseases, scarlet 
fever, measles, small-pox and vaccine disease, varicella, and typhoid 
fever. 



AETICLE Y. 



SCARLET FEVER OR SCARLATINA. 



Definition; Frequency; Forms. — Scarlet fever is an epidemic and 
contagious eruptive fever, characterized by a scarlet rash, which ap- 
pears on the first or second day of the disease, and ends usually about 
the sixth or seventh, or in rare cases as late as the tenth; by simul- 
taneous inflammation of the tonsils, and of the mucous membrane of 
the mouth and pharynx; and which is followed b}^ desquamation. 

The frequency of the disease is exceedingly variable in different years^ 
owing to its epidemic nature. This may be readily seen by a glance at 
the following table, which gives the annual mortality for the past sixty 
years in this city, from scarlatina and measles: 



Scarlatina. 


Measles. 


Scarlatina. 


Measles. 




Scarlatina. 


Measles. 


1809 


3 





1829 


9 


53 


1849 


242 


27 


1810 


2 


1 


1830 


40 


7 


1850 


440 


72 


1811 


3 


2 


1831 


200 


23 


1851 


391 


17 


1812 


1 


20 


1832 


307 


118 


1852 


434 


90 


1813 





1 


1833 


61 


1 


1853 


388 


14 


1814 





9 


1834 


83 


7 


1854 


162 


62 


1815 





7 


1835 


305 


248 


1855 


163 


24 


1816 





2 


1836 


240 


4 


1856 


992 


141 


1817 








1837 


205 


49 


1857 


704 


66 


1818 


1 





1838 


134 


123 


1858 


241 


28 


1819 


2 


108 


1839 


225 


136 


1859 


232 


51 


1820 


31 


47 


1840 


244 


2 


1860 


591 


15 


1821 


13 





1841 


83 


119 


1861 


1190 


74 


1822 


9 





1842 


220 


24 


1862 


461 


109 


1823 


11 


156 


1843 


395 


1 


1863 


275 


82 


1824 


9 


102 


1844 


269 


3 


1864 


349 


90 


1825 


9 


38 


1845 


199 


90 


1865 


624 


54 


1826 


4 


101 


1846 


221 


6 


1866 


491 


221 


1827 


1 


9 


1847 


344 


77 


1867 


367 


83 


1828 





68 


1848 


172 


99 


1868 


224 


108 



It will be noticed that for five successive years, 1813-17 inclusive, not 
a single death from scarlatina is reported ; and that during twenty years, 



FORMS. 695 

1S09-2S inclusive, only 99 deaths occurred from this cause; while in the 
single years 1856 and 1861, 992 and 1190 deaths respectively are re- 
ported. During the entire series of sixty years, there have been 13,016 
deaths from scarlatina returned. 

Hillier states, that during the eighteen years from 1848 to 1866, the 
deaths from scarlatina in London amounted to 52,461. 

It is impossible to estimate the actual relative frequency of scarla- 
tina and measles, owing to the abs^nceof any returns of non-fatal cases. 
It is evident, however, from the above table that, although the mor- 
tality from measles is also very variable, and thus may for a short time 
exceed that from scarlatina, in a long series of years the latter disease 
is far the more fatal. Thus the number of deaths from measles in this 
city, during the past sixt}^ years, amounts to but 2279. 

ilM. Guersant and Blache {Did. cle Med., t. 28, p. 173) state that it is 
less frequent than measles or variola. They added together the cases 
of the eruptive fevers collected in 1838 and 1839, by MM. Roger, Rilliet 
and Barthez, and Barrier, in the Children's Hospital at Paris, and found 
that there had only been 157 of scarlet fever; whilst there were 267 of 
measles, and 213 of variola and varioloid. 

The forms of the disease generally enumerated are the simple, angi- 
nose, and malignant. Authors differ widely in their descriptions of these 
three forms. Many of the English authors include in the simple form 
only the cases in which there is no affection of the fauces, while the angi- 
nose form includes all in which there is any throat affection whatever. 
M. Eayer, on the contrary, describes under the head of the simple form 
the cases in which the throat affection is mild, while he considers the 
anginose form to be that in which a pseudo-membranous angina occurs. 
Again, the descriptions of the malignant form are vague and uncertain, 
some including under this term only the rapidly fatal cases in which 
cerebral symptoms are present, while others include those also w^hich 
are rendered malignant by the occurrence of pseudo-membranous an- 
gina. 

We believe this division of scarlet fever into distinct forms and varie- 
ties to be, for several reasons^ a faulty arrangement. It is not, it ap- 
pears to us, in the first place, consonant with the nature of the disease. 
Scarlet fever is, in fact, with all its degrees of severity, and apparent 
differences, a single and distinct fever, produced by one cause, deter- 
mining similar effects, howsoever much they may vary in degree, and 
requiring no more than does typhoid fever to be divided into the variety 
of different forms, which it has been customary to ascribe to it. Again, 
the above mode of division is not, we are sure, a good one for practical 
purposes. It is impossible, indeed, as we have often found it, to refer 
many cases we meet with in practice, clearly and satisfactorily to any 
one of the forms of the disease described in books. The simple form of 
some of the English writers, or that in which there is no anginose af- 
fection, has no existence w^hatever, so far as we have been able to dis- 
cover. We believe that inflammation of the mucous membrane of the 
fauces constitutes an essential element of the disease, for Ave have 



696 SCARLET FEVER. 

never yet seen a case of scarlatina in which it was not present to a 
greater or less extent. It is often very slight, so slight, indeed, as to 
be unaccompanied by any evidence of pain in the part, but in all that 
we have examined, it has been decided and obvious. This supposed 
form of the disease does not, therefore, in our opinion, exist. 

The two other forms usually described, the anginose and malignant, 
are also of little value practically, since we have found that in all severe 
or grave cases, in which the patient did not die with violent nervous 
symptoms under the first shock of the scarlatinous poison, there has 
been developed a severe and dangerous anginose inflammation about 
the third or fourth day ; so that it is fair to say that we cannot im- 
agine any malignant case, lasting over the third or fourth day, which 
is not anginose, nor nuj severe anginose case, which might not also be 
styled, from its dangerous character, malignant. We have found it 
impossible, in our experience, to draw the distinction clearly and in- 
dubitably between the anginose and malignant varieties, because all 
severe cases partake more or less of the features of both. 

Feeling this difficulty of describing the disease according to the mode 
that had before that time been generally followed, and believing it also 
to be insufficient for practical purposes, we were led to attempt, in the 
first edition of this work, a different arrangement. 

We made, accordingh^, two forms or degrees of the disease, which we 
designated by the terms regular and grave. In the first form or degree 
we included all the cases in which the angina was simple and the erup- 
tion regular in all respects; in which there was no predominance of 
one set of symptoms over another^ but in which all held a due relation 
to each other. In this form was embraced all the cases of scarlatina 
simplex of writers, and many of those of scarlatina anginosa of the 
English authors. In the second form we included the cases which de- 
parted from the regular course of the disease, and which were rendered 
dangerous by the occurrence of severe symptoms not belonging in the 
same degree to the simple aff'ection. This form we subdivided into 
two varieties, the grave anginose^ which contained all the cases accom- 
panied by pseudo-membranous, ulcerative, or gangrenous angina; and 
the grave cerebral, which comprised all those marked by the early oc- 
currence of dangerous cerebral symptoms. The grave form compre- 
hended, therefore, some of the cases of scarlatina anginosa, and all 
those of scarlatina maligna of writers, dividing, however, those in which 
a pseudo-membranous, ulcerative, or gangrenous angina determined the 
type of the attack, from those in which the cerebral or nervous symp- 
toms gave to the case its stamp. 

More extended observation and more patient reflection have taught 
us that this division also is incorrect, — that it does not aff'ord a good 
classification for the purposes of description, and that it is defective as 
a guide in practice. 

We adopted, therefore, in the third edition, and shall follow in the 
present one, a diff'erent method of considering the disease, one which 
we believe to be more consistent with its nature, more suitable for the 



CAUSES. 697 

purposes of descriptioD, and much more likely to prove useful in prac- 
tice. We shall follow the same arrangement in regard to scarlet fever 
as that now generally employed for typhoid fever. We shall consider 
it as a single and distinct disease, and not as made up of a number of 
uncertain and imperfectly separated forms or varieties, since these so 
run into each other, as to make it absolutely impossible to draw the 
line clearly and palpably between them. The only division we shall 
make will be into mild and grave cases, since the only real difference 
between the cases is a difference in the degree of severity they ex- 
hibit. 

Causes. — It has been abundantly proved by long and reiterated ob- 
servation that scarlatina is propagated by two causes, contagion, and 
epidemic influence. Of these two modes of propagation, we have not 
the least doubt ourselves that the latter is by far the most active. 
It is only necessary to look over the results afforded by the tables of 
mortality for this city, as quoted in the early part of this article, and 
to observe that in some years the disease caused a heavy mortality, 
in others a very small one, and that in others again not a single death 
from it is reported, to be convinced that it is of a highly epidemic 
nature. 

The contagious character of scarlatina has been doubted by some few 
persons, but seems to us clearly proved by the evidence adduced by 
various writers. Our own experience also convinces us that it is a con- 
tagious disease, though much less so, we are sure, than either small- 
pox, measles, hooping-cough, or chicken-pox. We have quite fre- 
quently, indeed, known children exposed directly and for a considerable 
length of time to the infection to escape entirely, while it is extremely 
rare for us to meet with children, unprotected by previous attacks, who 
can resist the contagion of measles, hooping-cough, or varicella. But, 
though we believe it to be much less highly contagious than has been 
generally supposed, and than the other contagious diseases just named, 
we are also well convinced, as was stated above, that it is propagated 
to a considerable extent by a direct contagion. We have, in a number 
of instances, known one child in a family to contract the disease from 
direct exposure to it, or from the epidemic constitution of the atmos- 
phere, and a second, third, and even a fourth, to take the disease from 
the first, in five, seven, or nine days after the latter had fallen sick. In 
other instances, on the contrary, it would seem that either several chil- 
dren in one family contract the disease nearly simultaneously from the 
epidemic influence, or else that the period of incubation is sometimes 
very short. For example, during the winter season, a child five months 
old, who had never been out of the house, was seized with it. On the 
second day after the eruption appeared on this child, her sister, between 
four and five years old, fell sick, and on the third day another sister, 
the only remaining child, between two and three years of age. In the 
first of these cases it must have been contracted through the epidemic 
influence which was at that time prevalent in the city, since the child 
had. in no way been directly exposed to it. In the other two, we must 



698 SCARLET FEVER. 

either suppose the cause to have been the same, or else that the 
period of incubation was only two and three days in the respective cases. 

The period of incubation is shorter than in other contagious eruptive 
diseases. It may be stated to vary between twenty-four hours and two 
or three weeks. MM. Guersant and Blache are of opinion that in the 
majority of cases, it is from three to seven days. MM. Eilliet and Bar- 
thez found that of 38 cases in which the time was recorded, it was be- 
tween 2 and 7 days in 16, between 8 and 13 in 15, and 15 and 40 in 8 
cases. Our own observation would fix it at from 9 to 15 days in the 
majority of cases. 

Occasionally, however, it is very short; thus Trousseau mentions a 
case in which the evidence is almost conclusive that the period of incu- 
bation was less than twenty-four hours. Murchison also states that 
this latent period varies from a few minutes to five days, rarely, if ever, 
exceeding six days. 

It is impossible to state with any certaint}^ the length of time daring 
which the power of imparting the contagion continues in the patient. 
M. Cazenave (Abrege Frat. des Mai. de la Peau, p. 54), states that it 
lasts throughout the period of desquamation, and that it would even 
seem to be most active at that time. 

Whatever may be the duration of this period, it is certain that the 
virus may attach itself to clothing, bedding, or furniture, and that the 
disease may thus be transmitted b}' one who is not himself attacked. 
We also learn from some remarkable instances, as for example, from a 
case related by Eichardson in "TAe Asclepiad,'' that when the virus is 
thus attached to fomites, it may retain its activity for many months. 

In regard to the essential nature of the poison, it appears probable, 
in the first place, that it is contained in the secretions of the skin and 
fauces. 

The distance to which it may be carried by the air does not appear 
to exceed a few feet, and in those cases where prompt isolation does 
not prevent the communication of the disease, the virus has either 
been previously imbibed or is carried by fomites. It is probably of 
material nature, and is admitted to the system either through the 
skin, the respiratory, or, perhaps, the gastric mucous membrane. 

As we have seen, it retains its activity for a long time; but is ren- 
dered inert by a temperature somewhat below 212° F. 

Scarlatina is stated to be also inoculable, by the blood, the secretion 
from the fauces, and the fluid from the miliary vesicles which occasion- 
all}^ form on the skin. The resulting disease appears in some instances 
to have been favorably modified, but the operation has been compara- 
tively rarely practised. 

The epidemics of scarlet fever vary exceedingly in their extent and 
violence. During the years 1842 and 1843, the disease prevailed very 
extensively in this city, and assumed a malignant type, so that in a 
considerable number of families, two, three, and even four children, died 
within a very short period. 

During the winter of 1856-7, and throughout the spring of 1857, we 



INFLUENCE OF AGE. 699 

had one of the most prevalent epidemics that ever visited this city, and 
yet the proportion of deaths to the whole number of cases in our own 
practice and that of our friends, was such as to seem to show that the 
type of the epidemic was mild. 

The disease prevails at all seasons, but is most frequent in the spring 
and summer, and next in the autumn. It rarely occurs more than once 
in the same individual, but that it does so sometimes, is proved by facts 
brought forward by different authors. It has been asserted that second 
attacks of scarlet fever occur in the same person not more than once in 
a thousand cases. Of the truth of this assertion we are, however, very 
doubtful, since it has occurred to us to see no less than three examples 
of second attacks in our own experience. We attended in this city one 
child with perfectly well-marked scarlet fever, attested by subsequent 
anasarca, who had had the disease two years previously under the care 
of the late Prof. C. D. Meigs. In the winter of 1852, we attended two 
children in one family with the disease, one of whom died, and both of 
whom had had the disease four years and a half before. They were 
attended in the first attack by one of ourselves, and as it chanced, 
owing to our absence from tow|j during one day, thej^ were seen also 
by one of our friends, who made no exception whatever to the diag- 
nosis of scarlet fever. The only doubt as to these cases having been 
veritable examples of double attacks of the disease, must rest of course 
upon the diagnosis. In the first example, the diagnosis w^as made by 
Prof. Meigs in the first attack, and by one of ourselves in the second. 
In the two latter it was made bj" one of ourselves in both, accidentally 
confirmed in the first attack, in both children, by the opinion of a com- 
petent professional friend. The first attacks in the latter cases were 
both mild, but w^ell marked; the second were both severe, and one 
proved fatal on the sixth day. We have not the least doubt olirselves 
that all of the three were cases of true scarlet fever. If they were not, 
the two latter must have been cases of roseola, so closely resembling 
scarlatina as to oblige us to confess ourselves incompetent to distinguish 
between the two diseases. What adds to the certainty that the two 
which came under our own observation were examples of scarlet fever, 
is the fact that they occurred simultaneously with a third case in the 
same family. Now, roseola is not apt, so far as we know, to occur epi- 
demically in a household. Most of the cases of that disease that we have 
seen, have been solitary ones. Again, in the spring of 1857, one of us 
saw a well-marked attack of the disease in a boy nearly four years old, 
who had had it one year before, under the charge of a perfectly com- 
petent practitioner. 

Dr. Richardson (loc. cit.) asserts that he has known the disease to 
occur twice in the same patient, and also states that he himself has 
suffered from it three times. 

Age. — MM. Eilliet and Barthez state that it is most common from six 
to ten years of age. Of 251 cases that we have seen, in Avhich the age 
was noted, 64 occurred under 3 years of age, 78 between 3 and 5 j^ears, 
51 between 5 and 7, 47 between 7 and 10, and 11 between 10 and 15. 



700 SCARLET FEVER. 

From this it would appear to be more common in the first five years 
than between the ages of five and ten, since of the 251 cases, 142 oc- 
curred in the former, and only 98 in the latter period. By uniting the 
statistical tables of Dr. Emerson with those of Dr. Condie (Bis. of Child., 
2d ed., note, p. 86), we obtain the deaths from scarlatina in this city at 
different ages for a period of thirty years. These tables show clearly 
that the disease is most common between the ages of one and five 
years. The total mortality from scarlatina under ten years, during 
the time stated, was 2171, of which 132 were under one year of age, 
411 between 1 and 2, 1180 between 2 and 5, and 510 between 5 and 10. 

Of 148.829 cases collected by Dr. Murchison from the death returns of 
Great Britain, 9999, or about 7 per cent., were under 1 year; 30,974, or 
20 per cent., under 2 years; 95,070, or 64 per cent., under 5 years; 38,591, 
or 26 per cent., between 5 and 10; and but 13,168, or about 9 per cent., 
at all ages above 10. 

This agrees quite closely with the averages calculated from the ex- 
tensive statistics collected by Dr. Eichardson, which show the follow- 
ing percentage at different ages : 

« 

Under 5 years, 67.63 

From 5 to 10, . 24.33» 

" 10 to 20, 5.52 

" 20 to 40, . . . . . . . . 1.73 

" 40 upwards, 0.66 

Out of 12,962 deaths under 5 years, 1289, or 9.9 per cent., were under 
1 year; 2874, or 22 per cent., between 1 and 2; so that 4163, or 31.4 per 
cent., were under 2 years. 

The earliest age at which we have seen it perfectly well marked, was 
twenty-one days. We saw it once also in a child five months of age, 
and twice at the age of six months. It is not nearly so common in the 
first year of life as it is afterwards. The largest number of cases occur, 
according to our experience, in the third, fourth, and fifth years of life. 

The influence of sex seems not to have been determined with certainty. 
Dr. Tweedie (Cyclop, of Pract. lied., art. Scarlatina), says it is most 
common in girls. MM. Rilliet and Barthez, on the contrary, state it to 
be more common in boys. Of 262 cases under 15 years of age that we 
have seen, in which the sex was noted, 133 occurred in males, and 129 
in females. The truth is, probably, that under puberty it attacks the 
two sexes with about equal frequency, while after that age it is most 
common in females. 

It occasionally happens, that patients, both adults and children, who 
have undergone surgical operations, are attacked with a scarlatinous 
rash, with mild constitutional symptoms (Hillier, Gee). The disease, 
according to these authorities, is true scarlatina; and its occurrence at 
that time probably depends upon the system being in an unusually 
favorable condition for the reception of the virus. 

SyiMPtoms; Course; Duration. — As has already been stated, we in- 
tend, in our description of the symptoms of scarlet fever, to depart from 



SYMPTOMS OF MILD CASES. 701 

the ordinary mode of aiTungement of the subject. We shall discard 
the old division of the disease into three forms or degrees, scarlatina 
simplex, anginosa, and maligna, and substitute, for reasons already 
given, the simple division into mild and grave cases. We shall class as 
mild cases those which pursue an even and regular course, without 
being accompanied by dangerous or malignant symptoms, in which 
there occur neither violent nervous, nor threatening anginose symptoms; 
while among the grave cases we shall place those in which there occur 
severe nervous symptoms, in the form of violent delirium, coma, or con- 
vulsions, dangerous symptoms in the form of diphtheritic, ulcerative, 
or gangrenous inflammation of the mucous membrane of the fauces, and 
finally, those in which the general sj^mptoms assume a low and typhoid 
character. When it seems convenient, we shall follow the usual divi- 
sion of the course of the disease into the three stages of invasion, erup- 
tion, and desquamation. 

Mild Cases. — iStage of Invasion. — The following description of the 
symptoms of scarlet fever in its mild form is drawn partly from books, 
but much more from our own observation of 213 mild cases of the dis- 
ease, of all of which we have kept a faithful record, and, when there w^as 
anything peculiar or important, full notes. 

The onset of mild cases of scarlet fever is generally sudden. A child 
is ^vell, or so slightly ailing on one day, as that the change from its 
usual condition is not noticed at the time, though it may be recollected 
afterwards, and on the following day, or often within twelve hours or 
even less, the symptoms of the disease become marked and character- 
istic. In a large majority of the cases that we have seen, the eruption 
was already visible at our first visit. Frequently the patient has been 
put to bed well in the evening, and, becoming restless and feverish in 
the night, is found on the following morning with fever, sore throat, 
and very considerable eruption ; or, as happened in one of our cases, a 
child gets up in the morning apparently well, breakfasts as usual, goes 
to church, and falling sick while there, comes home and, a few hours 
later, shows the eruption over the neck and upper part of the trunk, 
and has fever and sore throat. In another case, a boy betw^een seven 
and eight years old was perfectly well in the morning. At 2 p.m., his 
mother, a most sensible and accurate person, observed him playing in 
the garden, and remarked upon his healthy looks. Fifteen minutes 
after this he felt sick at his stomach; he came into the house and went 
up to the nursery, looking pale and pinched, with a cold skin, and nearly 
fainted in the nurse's arms. He had then in the course of an hour 
three copious and watery stools, each one accompanied with vomiting. 
We saw him one hour after this, dozing, very pale, with pinched 
features, sunken and half-closed eyes, cool surface, and with the pulse 
at 128, and rather feeble. There was no eruption. At 6 p.m. we found 
him with a hot and dry skin, with the tongue heavily coated, the fauces 
swollen and showing flecks of exudation upon the tonsils, a pulse at 128, 
and with a well-marked scarlatinous eruption coming out abundantly. 



702 SCARLET FEVER. 

The case pursued a very regular course, without dangerous or malignant 
symptoms of any kind. 

But the invasion, though sudden in nearly all cases, is not always so 
precipitate as we have just described. When we come to analyze the 
early symptoms^ we find that the first one observed in most of the cases 
is fever, marked by considerable acceleration of the pulse and heat of 
skin. In some few cases the fever is preceded by the ordinarj^ pro- 
dromes of febrile diseases, languor, lassitude, pains in the back and limbs, 
and slight rigors. Simultaneously with the fever there is in nearly all 
cases more or less soreness of the throat. In all that we have examined, 
even those in which no pain was complained of, there has been redness, 
or redness with swelling of the fauces. In a majority of the cases 
vomiting occurs, or if not vomiting, some degree of nausea. There is 
complete anorexia; the thirst is acute; the bowels are usually in their 
natural condition, or slightly constipated. The child is quiet and dull, 
or else restless and irritable, and sometimes there is delirium; the face 
is generally flushed, and the eyes often slightly injected. The duration 
of these symptoms is irregular. They are said to last generally about 
a day, but they may continue either a shorter or longer period. We 
are very sure, from our own observation, as we have already stated, 
that these preparatory symptoms rarely precede the eruption more 
than twelve hours, and very often the time is even less, so that the 
eruption may even be the first symptom noticed. 

Stage of Eruption. — The eruption generally appears first on the face 
and neck, whence it extends rapidly over the whole surface. It con- 
tinues to increase in extent and intensity, so as to reach its maximum 
about the third or fourth day. It appears first in minute dark-red 
points dotted upon a rose-colored surface, forming patches of irregular 
shape, of considerable size, level with the skin, disappearing under 
pressure, divided at first by portions of healthy skin, but running rap- 
idly together, and giving to large portions of the surfiice a uniform 
scarlet color. The eruption is not generally equally diffused over the 
whole body, but is more marked upon one portion than another. It 
is often most intense on the back, and is there of a deeper color than 
elsewhere, not unfrequently assuming a purple hue. It is generally 
very well marked on the abdomen and thighs, and about the articula- 
tions, and assumes in those regions a particularly bright tint. 

It does not always cover the whole surface, but in some very mild 
cases, and, as we shall find when treating of the grave cases, in these 
latter, also, it may occur only in patches of moderate extent upon dif- 
ferent portions of the body, leaving us at times in some doubt as to the 
real nature of the rash. 

The surface of the eruption is smooth and even to the touch, unless, 
as not unfrequently happens, it is accompanied by the development of 
miliary vesicles, or crops of minute pimples or pustules. A certain 
degree of roughness is sometimes occasioned also by enlargement of 
the papillae of the skin in various parts of the body, particularly on the 
extensor surface of the limbs; but these are evidently independent of 



SYMPTOMS OF MILD CASES. 703 

the characteristic eruption. The skin upon some parts of the body, 
especially the face, hands, and feet, often presents a swollen appear- 
ance, rendering the movements somewhat stiff. There is in most cases 
a feeling of burning, irritation, and itching in the skin, the latter of 
which symptoms increases as the malady progresses. 

If the nail be drawn firmly over the skin where the eruption exists, 
a white line is produced^ which lasts for a short time and then passes 
away; if the pressure be more firm, a central red line with a, white 
streak on either side is developed. This was originally pointed out by 
Bouchut as pathognomonic of scarlatina, the peculiarity, according to 
him, consisting in the great duration of the white line so caused. It 
does not appear, however, to have any positive value in distinguishing 
this affection from many forms of erythema. 

The eruption generall}' reaches its height about the fourth day, and 
then remains stationary for one, or less frequently two days, after 
which it begins to decline. Its decline is marked by a diminution in 
the intensity of the color, w^hich, from scarlet, becomes red, then rose- 
colored, and growing paler and paler, finally disappears entirely about 
the sixth, seventh, or eighth day. In some very mild cases, however, 
the whole duration of the eruption is not over tw^o or three days, and 
in such the color it imparts to the skin is never very bright nor very 
deep, nor is it accompanied by intense heat, or by much irritation or 
itching. 

The symptoms w^hich preceded the eruption do not subside on its 
appearance, but persist or are augmented. The febrile movement con- 
tinues unabated ; the pulse is full, strong, and frequent, running up very 
soon after the onset to 120, 140, 150, and often to 160. This frequency 
of the pulse is, in fact, one of the most marked symptoms of the dis- 
ease. AVe have rarely, even in very mild cases, found it less than 140, 
and in not a few it has been in the first few days, and in children of 
four or six years old even, as high as 168 or 170. Occasionally, how- 
ever, it has been lower, and in a case that occurred to one of us, in a 
boy five years old, it w^as 96 on the second day, and only 88 on the 
third, though there w^as still a good deal of rash upon the skin. The 
skin is burning hot and dry, as a general rule, and loses its usual soft- 
ness and suppleness. The expression of the face is usually natural. 
The eye is often animated, and slightly injected. The respiration is 
generally easy and natural, though sometimes, when the fever is vio- 
lent, it becomes quickened. The auscultation and percussion signs are 
natural, unless some complication exists. There is often a rather fre- 
quent cough, which is dry, and evidently depends on the guttural in- 
flammation, and not on any bronchial or pulmonary affection ; it exists 
during the early period of the eruption, and declines with the inflam- 
mation of the fauces. The voice is seldom altered beyond having a 
nasal sound, so long as the disease continues simple and regular. If 
the voice becomes hoarse or whispering, it indicates an extension of 
the inflammation from the pharynx to the larynx. The anorexia con- 
tinues until the eruption begins to decline, and the thirst is acute up 



704 SCARLET FEVER. 

to the same period, when it moderates. At first the dorsum of the 
tongue is covered with a whitish or yellowish-white fur of variable 
thickness, while its tip and edges are of a deep red color. After two 
or three days, and during the course of the eruption, the coating just 
described disappears from the tongue, and its whole surface assumes a 
deep red tint and a shining appearance, which makes it look like raw 
flesh. At the same time it is often much diminished in size from con- 
traction of its tissues, and its papillae become enlarged and projecting; 
this condition generally lasts from six to ten days, after which it re- 
turns to its natural state; it is commonly moist throughout the attack. 
Vomiting is rarely troublesome in mild cases, though it often occurs; 
the bowels continue nearly in their natural condition; in some few 
cases slight diarrhoea occurs, but more frequently there is very moder- 
ate constipation. The abdomen is natural in most of the cases; some- 
times, however, there is slight distension and pain for a few days, 
which coincide generally with enlargement of the liver, or more rarely 
of the spleen. 

The urine during this stage usually presents the ordinary febrile 
characters; it is diminished in quantity, often of high color, though 
the pigment is not necessarily increased. The urea is not increased, 
which Einger regards as indicating that the kidneys are affected from 
the beginning of the attack. The chlorides are always more or less 
diminished. The phosphoric acid, according to Dr. Gee, is about nor- 
mal for the first three or four days; it then diminishes, and remains for 
a few. days at a half or a third of its normal amount. Uric acid ap- 
pears to be retained during the pyrexia, and excreted in excess so soon 
as it begins to subside. According to Holder's examination of 17 cases, 
there is bile pigment present during the first six days. 

Early in the second, or even in the first stage, the fauces present the 
signs of inflammatory action; the pharynx is reddened, and in some in- 
stances swelled; the tonsils enlarge and become red; the submaxillary 
and lymphatic glands are somewhat tumefied and tender to the touch, 
and when the case is at all severe, deglutition is generally painful, and 
in some instances extremely so. The absence of complaints of sore 
throat in a child, or the fact of its swallowing without hesitation or 
apparent difficulty, is no proof that angina does not exist, since we 
have always found upon examination in a good light much greater red- 
ness than natural, and in many instances redness and swelling com- 
bined. As the eruption progresses, and the tongue loses its coat and 
becomes red, the inflammation of the pharynx usually augments; the 
redness becomes deeper, and the tonsils are more swelled and painful, 
and, in a good man}-, but not by any means all the cases, are dotted over 
with small white spots, or with thin, whitish, and soft false mem- 
branes. The throat-affection, however, is rarely severe enough to con- 
stitute a serious danger in mild scarlatina, while in many of the malig- 
nant cases it is a frequent cause of a fatal termination. During the 
eruption, the nostrils are either dry and incrusted, or there is some 
coryza. The strength of the child is reduced for the time, but there 



SYMPTOMS OF MILD CASES. 705 

are no signs of prostration, and the decubitus is indifferent. There is 
almost alwaj'S more or less disorder of the nervous system, sometimes 
amounting only to headache and restlessness, while in other instances 
there is great irritability, wakefulness, and occasional delirium, especi- 
ally at night. 

Stage of Decline and Desquamation. — The eruption reaches its height, 
as alread}^ stated, about the third or fourth day, then remains station- 
avy for one or two days, and afterwards declines graduallj^, so that no 
traces are left on the sixth, usually, or at most, in rare cases, on the 
ninth or tenth day. In some very mild attacks, the whole duration of 
the eruption is not over two or three days. By the third day it has 
disappeared entirel}'. Such cases arc not, however, very common. 
The other symptoms, both general and local, decline with the erup- 
tion: the pulse loses its frequency, and falls to the natural standard; 
the heat of the surfiice first subsides and then disappears, but the skin 
remains soniewhat harsh; the redness and swelling of the tonsils and 
pharynx diminish; the spots of false membrane, if these be present, 
are thrown off; the deglutition becomes easy if it have been difficult, 
and soon all signs of throat-affection vanish; the tongue cleans off, be- 
comes reddish and glossy, and after a time returns to its natural state. 

At the time that the subsidence of all the symptoms takes place, 
desquamation begins. It dates, therefore, in most cases from about the 
sixth day, though it may be either earlier or later. According to Hil- 
lier, the date of commencement varies from the sixth to the twenty- 
fifth day. It commences in most of the cases on the face and neck, 
though in a few instances it appears first on the abdomen. It then ex- 
tends gradually over the body and becomes general. About the thorax 
and abdomen it occurs in the form of minute points, like those which 
result from the desiccation of sudamina; on the face it is in the form of 
thin light scales or squamae, while on the extremities large flakes of 
the epidermis become separated from the derm, and are removed 
by the child, or rubbed off by his movements in bed. The whole pro- 
cess usually occupies some ten, or twelve days, but may be prolonged 
into the third week, or even until the middle of the second month. It 
is generally accompanied by roughness and dryness, and some itching 
and irritation of the skin. Not unfrequently, the surface beneath the 
exfoliation is left tender and irritable for some time afterwards. 

During this period, dating from the sixth or eighth day, the urine 
becomes abundant, pale, of neutral or faintly acid reaction, and, accord- 
ing to Gee, deficient in phosphoric acid. 

Albuminuria is also frequently observed during desquamation, very 
much more so than during the eruptive stage. It is usually transient, 
but may continue until dropsy occurs. Sometimes the albumen totally 
disappears, and reappears w4ien dropsy comes on a fortnight or three 
wrecks later. The proportion of cases in w^hich this form of albumin- 
uria is present varies in different epidemics, from twenty-five or thirty 
to ninet}^ per cent. 

Temperature. — The fiery redness of the surface and the pungent char- 

45 



706 SCAKLET FEVER. 

acter of the heat, have led to much exaggeration in the description of 
the pyrexia in this disease. The range of temperature is indeed from 
100° to 105°, and only in rare cases does it reach 106°. 

In 30 cases reported by Einger (Med. Times and Gaz., Feb. 15th, 
1862), the temperature remained at the same point throughout the day 
in the more severe attacks; in slighter ones, it fell in the morning and 
rose during the day, being most frequently at its highest point between 
2 and 8 p.m. When the morning remission was marked, it indicated 
the approach of a favorable termination. The first decided fall of 
temperature, coinciding with a diminution in the eruption, occurred in 
the majority of cases on the fifth day, or if not on this day, it usually 
was deferred until the tenth or fifteenth. In these latter cases, how- 
ever, a fall of var3'ing extent had occurred on the preceding fifth days. 
After the marked fall on the fifth, tenth, or fifteenth day, the tempera- 
ture remains from 99° to 101° for a variable time, coinciding w-hen per- 
sistent, with continuance of the angina, or some one of the other lesions 
of the disease. If at any time after the complete fall of the tempera- 
ture, there is any considerable elevation again, it indicates the develop- 
ment of some sequel, either an affection of the kidneys, throat, or one 
of the serous membranes. It is thus seen that the temperature in scar- 
latina tends to form arcs or cycles, usually of five days' duration. 

Before quitting this part of our subject, we must remark that, though 
the above is a correct description of the usual symptoms of mild cases 
of this disease, the reader would be greatly deceived should he expect 
always, and invariably, to find this exact train of morbid phenomena. 
On the contrary, the mild and the grave cases both vary so much, that 
it is impossible to describe them accurately by one or two portraits. 
Taking the above sketch as a standard of the mild cases, the observer 
will find that many fall short of it in all their features, while others 
deepen graduall}' in their shades, so to sjoeak, until thej^ pass into the 
grave type. Those that are milder in their type than the above sketch, 
may be so in such a degree as to make it very difficult, and in some 
cases impossible, to determine positively whether the child has had the 
disease or not. Indeed, we doubt not ourselves that children some- 
times have the disease so slightl}', that it is not discovered by either 
the physician or parents, and, being protected by the attack, are in 
after-life classed amongst those insusceptible to the disease. Our 
grounds for asserting this are the facts that some cases we have seen 
have been so very mild that, but for the existence of the disease 
amongst other members of the famih'-, they might have passed unob- 
served ; and that in one instance we were sent for to see a patient, who 
had had the eruption for three days, and yet who was so slightly sick 
that he was sent for from school, to which he had gone, for us to see. 
It was a well-marked case, and the child had no troublesome symp- 
toms afterwards, notwithstanding the exposure he had undergone. 

A still more remarkable case occurred to one of us two years since, 
which shows clearly how a child may take scarlet fever without its 
being recognized by the family. 



SYMPTOMS OF GRAVE CASES. 707 

Case, — The mother of one of the families we attend consulted us about one of her 
sons, a sturdy boy of seventeen years of age. She stated that he had not been well 
for two days; that he had a severe sore throat, was restless and feverish at night, 
could eat nothing, and comphained of debility, but, as he was then going through his 
examination at the High School of this c\ij, he refused obstinately to remain at 
home. It was agreed that he should call at our office the next morning, on his way 
to the school. When he arrived, which he did on foot, as usual, we found him cov- 
ered with a copious, dark-red, perfectly characteristic scarlatinous eruption ; his 
throat was very red, swollen, and quite painful ; the pulse was over 120, active and 
full, and the skin hot. He was, of course, ordered home, there to remain until per- 
fectly well. He recovered and had no drawback. The distance from this boy's home 
to his school was not less than a mile and u half, and he had walked this distance 
twice a day. 

Grave cases. — The following description of the s^^mptoms of grave 
cases of scarlet fever is, like that which has just been given of the mild 
cases, drawn partly from books, and partly from oar own observation 
of the disease. Our own experience includes the careful observation, 
and a more or less full notation, of 61 grave cases. We shall include 
under this division of the subject, as already slated, most of the cases 
usually classed by writers under the title of scarlatina anginosa, and 
all those generally described under the title of scarlatina maligna. 

The sj-mptoms which mark the invasion of grave cases of scarlet 
fever, though sufficiently alike in all to show the unity of the disease, 
differ very materiall}' as to their degree of severity in different cases. 
In one set (rather less than a third, or 18 in 61, of our cases), they are 
most violent and dangerous, or, indeed, appalling in their character. 
From the first, they declare the imminent danger of the attack. In 
the second set (rather more than two-thirds, or 43 in 61, of our cases), 
they may be either evidently severe and dangerous, though not api>all- 
ing, as in the first, or they may be much milder, more like those which 
mark the invasion of mild cases, but even under these circumstances 
they soon put on their grave and dangerous character. 

The first set of cases, or those in which the symptoms are the most 
severe of all, and which include most of the malignant cases ordi- 
narily styled ataxic, usually begin with nervous symptoms. The 
onset is in some instantaneous. In one, the little patient, a girl two 
years old, whose brother and sister had been sick for some daj'S with 
scarlatina, was put to bed in the evening in her usual health, which 
was strong and vigorous. She slept quietly through the night, but 
was found by the mother the next morning in a state of drowsiness, 
violent fever, and covered with a deep-red scarlatinous rash. She soon 
became comatose, and died on the third day. In another case, a boy 
eleven months old was a little fretful in the afternoon, but was put to 
bed in the evening as usual and went to sleep. About ten o'clock the 
nurse heard a rustling in the bed, and on going to it, found him in a 
violent general convulsion. The next morning he was covered with a 
scarlet rash, which became deeper and deeper as the disease went on. 
On the second day he was nearly insensible, and had frequent attacks 
of convulsions; on the third day he had retraction of the neck, with 



708 SCARLET FEVER. 

Bpasmodie twitch ings, and at the end of that day, died in a state of 
coma. In a third case, a hoy six years old, whose sister had been sick 
for a week with a mild attack, went to bed well. At three o'clock in 
the morning, he was seized with vomiting and purging, paleness and 
coolness of the skin, and great exhaustion. At nine o'clock he was 
drowsy and dull, the skin was pale and cool, and the pulse extremely 
rapid; the vomiting and purging had ceased ; at 12 M. he was comatose 
and had a convulsion. From this time he continued comatose until he 
died at 6 p.m. of the same day, after an illness of fifteen hours. In a 
fourth instance, the invasion was that of croup; after a few hours 
came on coma and convulsions; patches of eruption then appeared on 
the trunk, and death occurred in twenty-four hours from the begin- 
ning. The subject of this case, a boy five years old, was thought to be 
so well in the afternoon of the day he was taken sick, that he had been 
sent out to visit a relation, and while there fell sick. In the fifth case 
the onset Avas sudden, with violent fever, drowsiness, deep suffusion of 
the skin, and in a few hours insensibility, general convulsions, and death 
in thirty-six hours. In a sixth, in a boy four years old, the attack came 
on with vomiting, paleness, drowsiness, and then a scarlet rash; after a 
few^ daj^S; corj^za and otorrhoea occurred; the tongue and lips became 
cracked and dry; in the second week the child was comatose, with occa- 
sional attacks of extreme jactitation, and the most violent hydrocephalic 
cries, which condition lasted ten daj's. After this there was diarrhoea, 
extreme emaciation, loss of speech, and entire deafness. Gradually, 
however, the fever disappeared, the tongue cleaned off, and intelligence 
very slowly returned; in the sixth week convalescence was firmly es- 
tablished, and the child recovered perfectly with the exception of his 
hearing, which remained very dull in consequence of the perforation of 
both membranse tympanorum. In a seventh, a girl eight years old, 
whose brother was then sick in the house with the disease, w^as in the 
morning well. At breakfast she said she felt sick and soon went to 
bed. At 5 p.m. of that day, she was attacked with a general convul- 
sion which lasted about fifteen minutes. The pulse, immediately after 
the convulsion, was 150. At 11 p.m. she had another convulsion. 
Through that night she was verj^ restless and wandering. On the 
morning of the second day, there was a third convulsion, which, how- 
ever, was very short. The pulse was now 160, small, and feeble. The 
patient was very heavy and dull, answering questions slowly and with 
great difficulty, and during part of the day she was comatose. On the 
third day she was better, the pulse having fallen to 152, and she was 
less dull, though she still continued very heavy and inattentive unless 
aroused by persevering efforts. The limbs were cool, while the head and 
trunk were hot. The eruption was thick on the trunk and upper part 
of the extremities; elsewhere it was scanty. Wherever it existed, it 
was of a deep red or purplish color, and the capillary circulation was 
sluggish and imperfect. On the fourth day her intellectual condition 
continued better, but the extremities w^ere still cold, and the lymphatic 
glands and subcutaneous tissues about the lower jaw and neck had 



SYMPTOMS OF GRAVE CASES. 709 

begun to swell. On the fifth day, the swelling had become very great; 
the stupor had returned; a profuse and disgusting coryza and otorrhoea 
had set in ; and the edges of the eyelids were inflamed and sore. On 
the sixth day the discharges from the mucous membranes of the head 
were very copious, and consisted of a thick, oifonsive, purulent fluid 
intermixed with dull whitish grumous particles. The patient was now 
comatose or very restless; she swallowed with great difficulty; the 
swelling under the lower jaw and about the throat was enormous; the 
pulse was rapid and small; the eruption was very dark in tint; the cu- 
taneous circulation was slow; the extremities w^ere cold, and death 
occurred about the middle of this day. Ln another case, the subject of 
which was a a'irl between three and four years old, the attack be<i;an 
with severe inflammation of the throat, causing great difficulty in 
swallowing. The rash on the first day was very extensive and of a 
deep-red color. The child was drowsy and heavy, or else delirious. 
On the second day she was comatose, and had strabismus and auto- 
matic movements of the limbs. On the third day the coma continued, 
and there were automatic movements of the extensor muscles, with re- 
traction of the head. The erujDtion continued vivid, but was of a dark- 
red color. Death occurred in the middle of the fourth day, in a state 
of coma, without convulsions. In still another case, a boy, between 
eight and nine years old, was attacked suddenly, while in good health, 
with vomiling, sore throat, and high fever. Twelve hours after the 
onset, he had a severe convulsion, which lasted fifteen minutes. He 
soon recovered from this, however, and remained perfectly intelligent. 
On the second day the rash was moderate; there was violent fever, 
and the child was heavy, but, when roused, still intelligent. Early in 
this day a severe fit occurred. This was most violent, as severe as the 
worst epileptic convulsion. It lasted one hour and three-quarters. 
The pulse, after this, was 145. On the third and fourth days, the 
symptoms improved very much, the pulse having fallen to 125 and 132, 
but be continued drowsy and heavy. The eruption came out most 
abundantly. The fauces were very much inflamed and somewhat ulcei"- 
ated, and the external lymphatic glands were enlarged, but still the 
swallowing was not difficult. On the fifth day he was not so well, 
being more restless and heavy alternately. There had now come on 
much difficult}^ in breathing, and some croupal sound. The latter symp- 
tom increased through the day, until the dyspnoea became very gi-eat. 
Deglutition now became excessively difficult; the external swelling in- 
creased; attacks of suffocation attended with the most painful and dis- 
tressing jactitation came on, and were renewed more and more fre- 
quently; and death occurred by asphyxia about the middle of the sixth 
day. In a tenth case, in a girl five months old, convulsions occurred on 
the second day. These were followed by coma lasting several days, and 
b}' enormous swelling of the lymphatic glands and subcutaneous tissues 
on the left side of the neck, and by a less degree of swelling on the right 
side of the neck. The glands of both sides suppurated and were opened, 
and the child finally recovered perfectly. In an eleventh case, in a 



710 SCARLET FEVER. 

boy seven years old, an attack of general convulsions took place on the 
third day, after which there were dcliriuni and coma alternately for 
several days, with coryza, angina, and offensive otorrhcea, lasting in all 
six weeks. The child recovered, but remained deaf. 

In this form of the disease, therefore, the symptoms are of the most 
virulent character. The onset is sudden. The child passes within a few 
hours from a state of apparent health, into one of the extremest dan- 
ger. Most of the cases begin with violent fever, and great depression 
of the strength. The pulse soon becomes verj^ rapid (140, 150, 180), or 
60 frequent that it cannot be counted, and it is at the same time small 
and often irregular. Tl^e skin is dry and burning hot in some parts, in 
others cool or even cold. Tiiere is general!}" nausea or vomiting, and 
these may be violent and constant. These are accompanied in some 
cases, but in our experience, only in the severest of all, by colliqua- 
tive diarrhoea and meteorism. Delirium often exists from the first, or 
else there is drowsiness and dulness of intelligence, vei-ging gradually 
into coma. In the most violent cases, the stu]~)or or coma alternate 
with convulsions, which may cause a fatal termination in eighteen, 
twent3'-four, or thirty-six hours. 

When a case of this kind lasts over three, or even two days, the vio- 
lence of the nervous symptoms almost always subsides; the convulsions 
cease to recur; the delirium is less violent; the coma gives way to 
drowsiness, or the patient becomes again quite intelligent and observ- 
ant; the pulse often falls in frequency, and the heat of skin may 
diminish, and the eruption assume a more favorable appearance. All 
the symptoms seem, indeed, to be more promising, and vcr}' often both 
the physician and friends ai'c greatly elated by the improvement in the 
patient's condition. Nor are these hopes always illusory, since children 
do recover occasionally even in cases that have exhibited the most 
threatening and malignant appearance at the moment of invasion. It 
hapj)ens, unfbrlunately, however, in a majority of such attacks, that 
the improvement which takes place on the third or fourth day is only 
momentar}'. The nervous symptoms subside, but new phenomena make 
their appearance in the shape of severe inflammation, membranous 
de))osit, and perhaps ulceration of the fauces, and extensive swelling 
and induration of the lymphatic glands and subcutaneous tissues about 
the angles of the inferior jaw, and under the chin and throat. In con- 
nection with the throat-affection which develops itself in this way, it is 
very common to have abundant purulent or membranous coiyza, and 
often also otorrhcea. The symptoms assume, in fact, the features of the 
cases usually described under the title of scarlatina anginosa. As we 
fihall, however, describe them directly in our account of the second set 
of grave cases, it is unnecessary to pursue the description at the present 
moment. We will state, however, before proceeding further, that the 
anginose and genei-al sj-mptoins which occur in cases beginning with 
violent nervous phenomena, and especialij^ with convulsions, are nearly 
always of the most dangerous and malignant character, and usually end 
fatally in two, three^ or four days after their appearance. 



SYMPTOMS OF GRAVE CASES. 711 

The eruption in this class of eases varies according to tlie violence of 
tbe attack. In the severest one that wc saw, that which proved fatal 
in fifteen hours, no eruption whatever was perceived, and we only knew 
it to be scarlatina by the character of the other symptoms, and by the 
fact that tiie sister of the boy had been sick in the same liouse with the 
disease for a week. In the case which terminated in twenty-four hours, 
the eruption siiowed itself in the form of scarlet patches about the face 
and upper parts of the body, twelve hours after the onset. In a third 
case the eruption was moderate, but perfectly well marked and general. 
In the other thirteen cases, which lasted, with one exception, not less 
than three days, the eruption was pei-fcctly well marked. It covered 
the whole surface, was at first scarlet in color, soon ran into a deep red, 
and then became violet or purplish. The exceptional case was one 
which lasted thirt3'-six hours, and proved fatal in that time. In this 
also, the eru|)tion was well marked and extensive. M. Guerctin (Arch, 
de Me'l., t. i, p. 292, 1842), in his account of the acute malignant form 
which he witnessed, states that the eruption was nearly constant. In 
all our cases it occurred within twent}^ four hours from the invasion, 
while in those of M. Guerctin, it appeared within twenty-four or forty- 
eight hours, or, as more frequentl^^ happened, not until the fourth or 
fifth day. 

If no favorable change takes place in these severe cases, and when 
they do not pj'ove fatal at once, the patient grows weaker and weaker; 
the delirium continues, or is replaced by coma; subsultus tendinum, 
rigidity of the limbs, spasmodic twitchings or genei'al convulsions, make 
their appearance; the eruption becomes more and more livid ; the pulse 
grows smaller, more frequent, and iri'egular; the respiration is exces- 
sively embarrassed ; deglutition becomes impossible; and the jiatient 
dies in from three to seven or nine daj's. In some few instances, the 
child struggles on for several weeks, and dies in a state of utter exhaus- 
tion, or, having a constitution of great powers of endurance, at lastsur- 
mounts the disease and recovers. 

The invasion of grave cases is not always, as wc have stated above, 
so violent as in those which have just been described. In rather more 
than two-thirds (43) of the CI grave cases tliat we have seen, the onset 
was less threatening than in the other thii'd, though the symptoms 
wei'c severe and dangerous in most of these also, and when not so at 
the very start, very soon assumed the serious characters which make 
it necessary to class the cases in which they occurred as grave. The 
chief ditferencc between the symptoms that mark the onset of grave 
cases of this kind, and of those in which the symptoms are still nioro 
violent, which latter we have thus far been desci'ibing, lies in the char- 
acter of the nervous phenomena — in the latter most severe, threatening, 
and dangerous, consisting of stujior, coma, or convulsions, and in the 
former, merely excessive agitation, restlessness, heaviness, or stupor. 
In one well-marked case of the kind now under consideration, the 
patient, a boy between seven and eight 3'ears old, was attacked in the 
evening with headache, fever, and vomiting. On the following morn- 



712 SCARLET FEYEE. 

ing a faint rash was perceptible, which, by the afternoon of that day, 
was distinct, thongli not very fulL The case now rapidlj' assumed un- 
pleasant features. The pulse rose to 150. There was much drowsiness 
and delirium, and on the fourth day constant picking at the bed-clothes 
and at the finirers. In another case, in a bov between four and five years 
old, the first sign of sickness was slight languor after dinner, which 
was followed by fever in the evening, and the development in tlie course 
of the night of a scarlatinous rash. On the following day, there was 
Konie pain in the throat, with redness; the pulse was 140, and the skin 
hot and dry ; there were no nervous symptoms, except slight drowsiness. 
On the third day the pulse was 136, the rash was well out, and there 
were no unpleasant symptoms Avhatever. From this time, however, the 
symptoms gradually grew worse ; the throat-affection increasing, the 
cervical lymphatic glands becoming very much swelled, and the child 
growing more uneasy and restless, though retaining perfectly its intel- 
ligence. By the sixth day, the grave character of the case was fully 
developed, the eruption being intense, and of a deep brick-red, verging 
towards a purple color. There was at the same time very great drow- 
siness, abundant discharges from the nasal passages of thick sero-mucous 
and purulent fluids, membranous exudation in the fauces, with gurgling 
and great difficulty in swallowing, and an ntter loss of appetite. In a 
third case, a boy between one and two years old was a little fretful in 
the morning, and was seized in the evening with vomiting and fever, 
and very considerable restlessness. On the next day he was covered 
with a scarlet rash from head to foot, and the skin was fiery hot. The 
pulse was 160, regular, not large. The child was very drowsy, dozing 
nearly all the time, but quite intelligent when aroused. The fauces 
were intensely red and rough, and the tonsils much swelled; there was 
very little external swelling. On the third day he was still very drowsj', 
and, when roused, less observant than before, though he still recognized 
persons. The pulse was 168, small, difficult to count, very hard and 
corded. The skin, especially that of the limbs, was scarlet, very hot, 
and dry; the cutaneous capillary circulation was good. After this the 
symptoms grew rapidly worse; the pulse continued at from 148 to 168 
on the fourth and fifth days, and on the sixth rose to 172, at which it 
stood a few hours before death. On the fourth and fifth days, he was 
still very heavy and drowsy, and so much so on the former as to take 
no notice whatever except when moved. On the fifih day, an abun- 
dant sero-mucous discharge took place from the nostrils; the cervical 
lymphatic glands, which had begun to swell before, now increased in 
size; there was some loud faucial gurgling, and the swallowing became 
difficult. On the morning of the sixth day, some of the symptoms 
improved so much as to flatter very greatly some of his attendants, 
who were unacquainted with the treacherous character of the disease. 
He roused up from his state of stupor, and noticed several things that 
were shown him, even taking them into his hand; but the breathing 
continued bad, the lymphatic glands were swelling rapidly, and bad 
already become vei-y large, so that they formed great projections on 



SYMPTOMS OF GRAVE CASES. 713 

either side of the neck. The pulse was 155, and small. In the middle 
of the day the breathing became difficult, from the internal and exter- 
nal swellino', and from the collection in the fauces of thick and viscid 
phleg-m. The surface had now become pale. The tumeAiction about 
the neck was immense. Down the front of the neck and along its sides 
to the clavicles, a kind of cedematons swelling of great size had come 
on, and was rapidly increasing. The pulse was 160, small and feeble. 
The legs and arms were of a dark, congested tint. Deglutition was 
excessively difficult. In the evening the pulse was 172, and death took 
place just before midnight with slight convulsive movements. 

The mode of invasion is different, therefore, in different examples of 
the kind of grave cases now under consideration. In some it is even 
milder than in any of those that have just been -detailed 5 and it is not 
until the third, fourth, or fifth day, or even later, that the severity of 
the attack shows itself fully and unmistakably. 

After the disease is once established, it will be found upon examina- 
tion, that the fauces are of a deeper red color, and that they are more 
swelled, than in mild cases. At the same time there is more difficulty 
and pain in deglutition; these are complained of by older children, and 
are shown in those who are younger by their refusal to swallow, by 
their crying upon making the attempt, and in some instances, especi- 
allj' at a later period of the sickness, by a positive inability to perform 
the movement. In nearly all of these cases, false membrane is formed 
upon the mucous membrane of the throat. This is never, or ver}^ 
rarely, present on the first day of the attack. In most cases it is not 
found until the second or third, and often not before the fifth or sixth 
day. MM. Eilliet and Barthez state that they have known it not to 
appear until the tenth and eleventh days. It appears first in small, 
thin, whitish, yellowish, or ash-colored points or patches, on one or 
both tonsils, or on the soft palate only, where it remains limited, or 
from whence it extends to the pharynx, which it may cover in whole 
or in part. The patches are of variable thickness and consistence, and 
adhere sometimes very slightly, and sometimes with considerable tenac- 
ity to the mucous membrane beneath. They may remain for a day, 
and then be thrown off not to be again produced; or they may form in 
several successive crops, until the case is terminated ; or, as most fre- 
quentl}^ happens, they last three or four days or more, and are then 
detached. The mucous membrane upon which they are seated is found 
in various conditions. It may present the redness and sw^elling indica- 
tive of severe inflammation, or it may be softened, ulcerated, and, ac- 
cording to MM. Guersant and Blache, gangrenous, though as a gen- 
eral rule, what have been supposed to be sloughs are in fact portions 
of altered false membrane. There is more or less fetor of the breath, 
sometimes amounting to a gangrenous odor, after the appearance of 
the pseudo-membrane. The severity of the sj^mptoms is in proportion 
to the extent and thickness of the false membrane. 

We have already seen that it is not uncommon to find ulcei'ations 
beneath the false membranes. In other cases of this kind the throat- 



714 SCARLET FEVER. 

affection assumes very great violence without the presence of an}" exu- 
dation whatever. In some the mucous membrane is of a deep red or 
even purplish hue, its consistence is softened, and it is swelled and cov- 
ered with a la^'er of gra3'ish or sanious pus. The tonsils are enlarged, 
infiltrated with pus, softened, and break down easily under the finger. 
In other cases, in addition to the redness and softening, ulcerations are 
present. These may be superficial, amounting only to erosions, or they 
may extend through the mucous, and even submucous tissue to tiie 
muscles beneath. They are seated generally in the phar^^nx, but may 
exist also on the tonsils, and in some rare cases they extend into the 
larynx. In still more malignant attacks of the disease, we find evi- 
dences of gangi-ene of the pharynx. It is important to distinguish be- 
tween those in which the pseudo-membrane becomes so changed as to 
assume the nppearancc of sloughs, and those in which the tissues of the 
pharynx are really gangrenous. The former constitute by far the 
greater number of the cases which have been generally regarded as in- 
stances of gangrene of the throat. That gangrene of these tissues 
does actiiall}' occur in sonic few cases, is proved, however, bj' the evi- 
dence of Dr. Tweedio, who says (loc. cit., p. 650), that in malignant 
scarhiiina '"the membrane of the ])luuynx is sometimes of a dark, livid 
color, and occasionallj^ in a sloughing state," and by that of MM. Guer- 
sant and Blache, who state that they met with several instances of gan- 
grene of the pharynx in the pseudo-membranous angina which pre- 
vaileil in 1841. 

An almost constant accompaniment of cases of this kind is inflam- 
mation and swelling of the submaxillary Ij^mphatic glands and sur- 
rounding cellular tissue. The tumefaction is generall)^ confined at first 
to the glands beneath the jaw, which become painful to the touch. 
After a short time it extends to the parts behind the angle of the jaw, 
and beneath that bone, until at last the sides of the ueck and the throat 
are largely distended, so as to interfere with, or even prevent in great 
meiisure, the opening of the mouth, and by the pressui-e exei'ted on the 
internal parts of the throat, to add to the difficulty of deglutition which 
already exists. In some cases the pressure is so considerable as to em- 
barrass the respiration of the child. This swelling has been generally 
supposed to depend on inflammation of the parotid glands; but MAI. 
Bretonneau, Guersant and Blache, and Eilliet and Barthez, all state 
that ])ai'otitis is of exceedingly rare occurrence, and that the swelling 
in question depends nearly always on the causes just described. The 
last-na-ned writers state, moreover, that the tumefaction of the cellular 
tissue is often of the nature of active oedema. The swelling of the 
cervical lymjihatic glands, and of the cellular tissue of the sides of the 
neck, and that under the throat and chin, seldom takes place to any 
considei-able extent, according to our experience, prior to the third or 
fourth day. During the first two or three days, the chief symptoms 
are the fever, the eruption, and the nervous phenomena, which latter 
consist, in this class of cases, of either excessive agitation and restless- 
ness, or of drowsiness or stupor. Yery often, after a child has seemed 



SYMPTOMS OF GRAVE CASES. 715 

to be very ill for two, three, or four da3's, from the violence of the feb- 
rile reaction and the severity of the nervous symptoms, it will a])pear 
to improve very decidedly on the third or fourth day, and elevate 
greatly the hopes of those interested in it. It is just at this time, how- 
ever, that the throat-affection is a])t to set in severely; and, moreover, 
it rarely fails to come in children who have presented violent symp- 
toms during the first three days. The enlargement generally disap- 
pears, in favorable cases, in from three to twelve days, b}' resolution, 
while in others it terminates by suppuration of the glands and sur- 
rounding parts. 

In the form of the disease we are now considering, it is common to 
observe violent conjza, which may be either purulent or pseudo-mem- 
branous. It may appear from the very fii'st, or not for several daj^s 
after the eruption has commenced. The discharge is 3'ellowish, granu- 
lar, thin at first, and afterwards thick; it contains often flakes and 
shreds of exudation, and becomes sometimes very offensive, and highly 
acrid, so as to excoriate very much the upper lip. It often flows in sur- 
prising quantities, and genei-ally continues up to the moment of death, 
or until all the S3'mptoms have moderated. 

Otorrhcea is another sj'mptom of this form. It generallj^ occurs simul- 
taneouslj" with coryza. The discharge is at first thin and wateiy, like 
that from the nostrils, but becomes gradually thicker as the case ad- 
vances. The quantit}^ is extremely variahle. In some cases we have 
known it to fill the meatus and concha of each ear, and then to flow out 
and make large stains u])on the pillow, or to collect vavy i*a])idl3^ after 
being wiped awa^^ It is, like the corj'za, an unfavorable sym|)tom, as 
it is a mark of the grave form of the disease, and because, if tiie child 
recovers, it is very apt to result in deafness, which is but too often per- 
manent. 

These s^ymptoms, coryza and otorrhoea, sometimes exist also in mild 
cases, but they do not then assume the peculiar characters which they 
present in grave cases. The discharges are much less abundant, and 
the mucus or pus is health}^, and scai'cely offensive to the smell; the.y 
last but a short time, and are very rarel^^ accompanied at the time or 
followed by more than a slight degree of deafness. 

The eruption is generally stated to appear later than in mild cases, 
and often to be less vivid and less extensive. It is also said to occupy 
only poi'tions and not the whole of tlie bodj*, to occur in irregular 
patches, or to appear and disappear alternately. This has not been 
the case in the instances which we have seen. In all but two of the 
fortj'-one, the eruption occurred earlj", generally within twenly-four 
hours from the onset. It was of a deep brick-red or livid color, and cov- 
ered the whole surface. In one of the exceptional cases it did not take 
place until the seventh day, when it appeared in j^atches on the wrists 
and knees. On the eighth day, it extended to the rest of the extremi- 
ties and abdomen, and on the ninth was general and of a rather dark 
hue. In the second exceptional case the eruption did not appear until 
the second day. It then came out over the whole trunk, and to a mod- 
erate extent upon the limbs also. In this, as in the previous one, it 



716 SCARLET FEVER. 

was dark in its tint. In three other cases it was quite moderate in 
amount, but general and well-marked. 

The general symptoms are more severe in grave than in mild cases. 
It sometimes happens that for one or two da3'S, or even longer, the case 
promises to be mild, but then suddenly assumes the threatening features 
of the form under consideration. The fever is usuall}^ intense, the pulse 
being full and strong, and rising very soon after the onset to 140, 150, 
or 170; the skin is ver^^ hot and dry; there is more restlessness and 
irritability than in the mild form, and after one, two, or three days, 
appears a strong disposition to delirium and stupor, not unfrequently 
mei-ging into coma. The respiration is accelerated, and in many in- 
stances, owing to the throat-affection, labored and difficult. In most 
of the cases, a loud gurgling, which is very characteristic, is heard in 
the tliroat, particularly when the child is asleep or dozing. This de- 
pends in part upon the collection of viscid and tenacious secretions in 
the fauces, — which sometimes embarrass the respiration so much as to 
make it necessarj- to remove them with a mop. — and in part upon the 
existence of the corj'za of Avhich we have spoken. The coryza is a 
sj'mptom of very serious consequence at all ages, but especially in 
young children. There is generally some cough, which may be frequent 
and troublesome, though not usually so unless there be a disposition to 
larj'ngeal complication. The voice is hoarse, guttural, and sometimes 
whispering. When the cough is very frequent, and still more, when it 
becomes hoarse and croupal, in connection with hoarse or whispering 
voice, or aphonia, there is great reason to fear the extension of the ex- 
udation into the larynx, which constitutes an almost necessarily fatal 
accident. The face is deeply flushed at first, and the expression anxious. 
If no improvement take place, the case assumes in four or five days, or 
even less, a still more threatening aspect. The pulse becomes very 
rapid and small; the restlessness and delirium pass into drowsiness or 
coma; the tongue becomes brown and dry; the teeth are covered with 
sordes; the lips are dry, cracked, and bleeding; diarrhoea is apt to 
occur; and the patient dies in from three to ten days, in a well-marked 
typhous condition. In other instances, on the contrary, the case runs 
on from week to week, and at last, after an illness of four, five, or six 
weeks, the child either dies or recovers after all chances for life seem 
to have been lost. 

In order to show, in their natural connection, the different symp- 
toms that have just been described, we will cite the following abstract 
of three of our cases. The first occurred in a boy between seven and 
eight years old. On the fourth day of the attack the pulse was at 150, 
and the fauces presented flakes of false membrane. The fauces were 
very much swelled, and deglutition became difficult; faucial gurgling 
came on, and the throat was filled with viscid and tenacious secretions. 
The nasal passages now became occluded by constant discharges, at 
first mucous and then muco-purulent, with admixture of membranous 
particles. From the fifth to the ninth day there was an excessive 
fetor from the nose and mouth. The lymphatic ganglions just beneath 



SYMPTOMS OF GRAVE CASES. 717 

the ear swelled veiy greatly, so as to extend much beyond the line of 
the inferior maxilla. The tongue and lips became dry and cracked, 
the teeth were covered with sordes, and the angles of the eyelids in- 
flamed and then ulcerated. On the sixth, seventh, eighth, and ninth 
days, there were taken away from the mouth and throat of the child, 
with a mop, hard and most offensive masses of dried-up mucus and in- 
crusted epithelium, enveloped in thick, glue}', dark-colored mucus. 
These masses stuck to the fauces, tongue, and lips, so tenaciously, that 
they could be removed only by means of a mop, the boy himself being 
quite unable to detach them. On the seventh, eighth, and ninth days, 
though the cervical lymphatic glands were very much swelled, the 
patient was better. The pulse came down graduall}^ from 152 to 132, 
128 and 112, and the swallowing improved so much that the child 
could take liquids with less convulsive effort, and could drink continu- 
ously. The drowsiness diminished, and the delirium ceased. On the 
eighth day a slight erythematous redness appeared on the bridge of 
the nose, and extended towards the malar bones. The skin of the face 
and eyelids became somewhat swollen and puffed by an cedematous 
effusion. On the ninth day the pulse was down to 104, and the skin 
was nearly natural as to temperature. The swelling was very great 
on both sides of the neck, and the glands on the right side were red on 
the surface, very hard, and quite painful. The swallowing was much 
easier for drinks, but as yet no solid, not even of the softest kind, could 
be taken. On the fourteenth day from the onset we opened a very 
large abscess on the left side of the neck, which discharged abundantly 
a healthy and laudable pus. On the fifteenth day we opened a still 
larger abscess on the right side, and, after this, perfect recovery took 
place. 

In another example, which has been alluded to already, occurring in 
a boy between four and five years old, the gravity of the case did not 
show itself clearly until the sixth day. On the evening of that day 
the pulse was 128, the skin very hot and dry, and there was an intense 
eruption of a brick-red color. There was, at the same time, great 
drowsiness, and utter loss of appetite. Deglutition was difficult, and 
there was a loud faucial gurgling during sleep. There was now 
also a considerable amount of membranous exudation in the fauces. 
During the seventh and eighth days, the boy continued very sick. He 
was drowsy, almost comatose; the eyes were half open and the con- 
junctivae minutely injected; there was an abundant coryza, the dis- 
charges being composed of offensive mucous and sero-mucous fluid, 
with an admixture of pus and of flocculent or grumous particles, the 
latter consisting evidently of broken-down membranous exudation. 
There was no otorrhoea. The pulse rose from 120 to 128. During the 
night of the seventh day the anginose affection was so severe that the 
child could swallow nothing from 10 p.m. to 3 a.m.; fluids poured into 
the mouth ran out again in part, and were in part returned through 
the nostrils. On the tenth day there was still no decided improve- 
ment, except that the j^ulse had fallen to 112. The coryza continued 



718 SCARLET FEVER. 

as before; tlie fauces were covered thicklj' with whitish exudation; the 
deglutition was a little easier. The drowsiness continued, as the child 
dozed nearh^ all the time, merelj^ rousing from time to time to take 
drinks, and then, in spite of all solicitation, sinking into sleep again. 
The abdomen was tympanitic. The urine was rather free, more so 
than it had been before, and it was also clearer and of a lighter color. 
By the twelfth daj^ there was a decided improvement; the pulse had 
fallen to 106, and the child was not quite so heavy. The act of swallow- 
ing was easier, and the fauces showed less of the plastic exudation, but 
they were still very much coated with tenacious mucus. On the thir- 
teenth and fourteenth days the patient continued to mend. The pulse 
foil to 98 and 92; the fauces had become clear of the exudation, and 
presented instead an excoriated and ulcerated appearance. The secre- 
tions into the fauces were less viscid and less copious. The coryza had 
diminished, and the discharges had become first muco-purulent and 
then raucous. The drowsiness had diminished, so that he waked 
spontaneously and began to ask for his toys. He now began to de- 
mand food, but refused to eat w^hen things were brought to him. On 
the fifteenth day he was extremely irritable, screaming most violently 
for the slightest causes. On the sixteenth day the pulse was 92, and 
the skin nearly natural as to temperature. He was now exceedingly 
emaciated and very weak. The orifices of the nasal passages were 
verj^ much irritated and incrusted, but there was scarcely any coryza. 
The tongue was clean, pink in color, and moist, the thirst not too 
great, and there w^as a little appetite. The temper was improving. 
From this time forward the child improved steadily but slowly, so that 
he sat up for the first time on the twenty-seventh day. He was as 
much emaciated at that time as after violent typhoid fever. 

The reader must not, however, suppose that all grave cases present 
throughout their whole course, symptoms so dangerous as those which 
marked the two examples that have just been detailed. In some, on 
the contrary, the symptoms, though of such a character as to deserve 
and require the title of grave, are of a much milder kind. In order to 
make this part of our description of the disease as clear as may be, we 
Avill relate the following as an example of a grave case in which the 
symptoms, though severe, were neither malignant, nor at anyone time 
very dangerous to life. A girl between seven and eight years old was 
well at breakfast. In the course of the morning she complained of sore 
throat, and of not feeling well, and at 4 p.m., when we saw her, Avas 
quite feverish, with a frequent pulse and hot skin, and showed already 
a well-marked but rather faint scarlet rash upon the trunk of the body, 
and about the elbows. On the following day the trunk and upper parts 
of the limbs w^ere covered thickly with an intense eruption, of a bright 
scarlet color. The fauces were very red, somewhat roughened and a 
good deal swelled. The only nervous symptom present was severe 
frontal headache. There was no unusual agitation, no drowsiness, and 
nothing like convulsive movement. On the evening of this day, the 
pulse had run up to 168, and was rather full, but not hard. The skin 



SYMPTOMS OF GRAVE GASES. 719 

was exceedingly hot and burning; during the night there was great 
restlessness, and the child was wakeful and occasionally delirious. On 
the third day the symptoms continued much the same, except that the 
pulse was down in the morning to 152, that the rash had extended to 
the hands and feet, and that some small spots of whitish exudation 
were now visible on each tonsil. On the night of this day the fever 
af!;ain increased very much, and the child was again delirious. On the 
fourth day the pulse was 148; the exudation had increased so much as 
to cover a good portion of both tonsils, and it had extended also in a 
slii^ht degree to the posterior wall of the pharj^nx. There was now a 
considerable enlargement of the lymphatic glands situated at the angle 
of the jaw on the left side, and a smaller one on the right side. Deglu- 
tition was somewhat painful, and a little difficult, but not seriously so. 
The case continued in much the same way until the seventh day, when 
the pulse had fallen to 132, and the eruption had faded very much on 
the trunk of the body, and, to a considerable extent, upon the limbs 
also. The fauces now exhibited the false membrane over the whole of 
both tonsils, over the half-arches, the sides of the uvula, and upon the 
upper portion of the posterior wall of the pharynx. Instead of being 
whitish and clean-looking as at first, however, the false membranes 
now looked exactly like sloughing portions of the mucous membrane. 
The}' were of a dirty bi'own color, softened, and seemed to be detach- 
ing themselves like sloughs from the tissues beneath. On the ninth 
day the patient was much better, the pulse having fallen to 116; the 
eruption had almost wholly disappeared; the heat of skin was very 
much reduced; the dark-colored portions of false membrane had dis- 
appeared from the fauces, leaving the mucous membrane beneath red, 
excoriated, and in parts ulcerated. On the thirteenth day, the child 
was convalescent, the pulse having fallen to 96, the heat of skin having 
disappeared, and the throat being nearly well. The appetite had re- 
turned, the temper was serene and cheerful, and the patient was, in 
fact, well, with the exception of weakness, and some remaining sore- 
ness of the throat. 

Laryngitis has been supposed by some persons to be of frequent oc- 
currence in the course of the disease, while others assert that it rarely, 
if ever, occurs. M. Bretonneau has never met with it. M. Eayer says 
he does not know that the exudation has ever been found in the larynx 
or trachea. Tweedie {Cyclop. Fract. Med., Art. Scarlatina, p. 640) 
states that in the dissections he has made he has not seen an instance 
of the membranous exudation extending into the larynx. That it does 
sometimes occur, is proved nevertheless, beyond a doubt, by the evi- 
dence of MM. Guersant and Blache, Hilliet and Barthez, and others, 
and by our own observation. MM. Rilliet and Barthez report three 
cases in which it was found in the larynx after death. These gentle- 
men slate, however, that they have never observed the peculiar symp- 
toms of croup. This does not accord with our own experience ; for in 
several cases that we have seen, all the peculiar symptoms of that 
malad}' were present during life. The subject of one of these cases 



720 SCARLET FEVER. 

was a boy two years of ago. A few days after the invasion of the dis- 
ease, a severe and extensive pseudo-membranoas angina was developed. 
This was soon followed by all the symptoms of. croup — hoarse cough, 
stridulous respiration, weak, feeble cry, dj'spnoea, and whispering voice, 
wliicli lasted about five days, when the angina and croupal sj^mptoms 
both diminished very much, and the child seemed in a fair wa}^ to re- 
cover : suddenly, however, extensive tumefaction of one side of the 
neck took place, and he died in twenty-four hours. Unfortunatel}" no 
examination could be made. In another case, in a child between six 
and seven years old, who had a most violent attack of the disease, 
severe croupal sj'mptoms set in on the eighth day. They consisted of 
harsh, croupal cough, stridulous respiration, and great diflnculty in 
swallowing, and the act of swallowing occasioned much harsh cough 
and strangling. The symptoms continued on the ninth day. after which 
they moderated, and the child finally recovered entirely. In a third 
case, also a violent one, in a boj' betw^een eight and nine years old, and 
in which general convulsions occurred on the first and second days, the 
symptoms had improved a good deal on the third or fourth day. On 
the fifth day he was not so well, being more restless and heavj', and 
having much diflSculty in breathing, with some croupiness of sound. 
These symptoms increased rapidly until they gave rise to most violent 
fits of suff*ocation, and caused a fatal termination on the sixth day. In 
a fourth case, in a child nine months old, death occurred on the thir- 
teenth day from laryngitis, occurring in connection with membranous 
angina. The fatal termination was preceded by hard, dry, and croupal 
cough, stridulous respiration, and great difficulty of deglutition. In a 
fifth, in a child under a year old, croupal symptoms made their appear- 
ance on the sixth day, the fauces being at that time covered with mem- 
branous exudation, and they caused or assisted to cause a fatal termi- 
nation on the eighth da}'. In yet another case, the subject of \vhich 
was between one and two j^ears old, a grave attack of scarlet fever was 
entirely recovered from. At the end of the second week the child was 
seized, owing to improper exposure in a cold house, against which the 
parents had been properly warned, with anasarca. This also was re- 
covered from, and again the parents were warned against improper 
exposure. On the very day after our last visit, however, the child was 
taken down stairs into a room with the windows open, and this on a 
mild day in the month of February. The child was seized now with 
diphtheritic angina, and died, after a few days, of croup. This was in 
the fourth week from the onset of the scarlet fever. In a seventh case, 
severe from the beginning, the patient recovered so as to be apparently 
out of danger, but, owing to tlie room being very cold from the fact 
that it was large, with wide rattling windows down to the floor, and 
from the fire being too small, the child took cold, and, at the end of the 
third week, was seized with severe croup, which had many of the fea- 
tures of membranous croup, but which was, in all probabilit}', spas- 
modic croup, dependent on ulcerative laryngitis. The case continued 



SEQUELS — DROPSY. 721 

seven days, during which time the patient was violently ill, but finallj^, 
after a most dangerous struggle, it ended favorably. 

The symptoms which indicate a disposition to implication of the 
larynx are frequent, hoarse, and croupal cough, hoarse, and whispering 
voice or cry, aphonia, and dyspnoea with stridulous respiration. 

The duration of grave cases of scarlet fever is very uncertain. In 
some the disease runs its course with frightful rapidity, destroying life 
within a few hours or days. In others, though the symptoms of the 
early stage may seem to be as violent as in those where death occurs 
in a very short space of time, the patient either lingers for several 
days or two or three weeks, and then dies, worn out by the violence 
or malignancy of the attack, or else, after a most dangerous and 
aj^parently desperate illness, he finall}' struggles through and recovers. 

In the most violent of the grave cases, those which we described first 
as forming a separate group, 18 in number, of which 13 proved fatal, 
the duration in the fatal cases was between eighteen hours and six days. 
Of the 13, 2 proved fatal in eighteen hours, 1 in twenty-four hours, 2 in 
thirty-six hours, 4 in three days, 1 in four days, 1 in five da3^s, and 2 
in six days. Of the 5 favorable cases, 1 lasted three weeks, 1 four weeks, 
2 six weeks, and 1 two months. 

Of the less violent of the grave cases, 43 in number, 15 died, and 28 
recovered. Of the 15 fatal cases, 1 died in four days, 2 in five days, 2 
in seven days, 3 in eight days, 2 in thirteen days, 1 in fourteen days, 1 
in fifteen days, 2 in four weeks, and 1 in five weeks. Of the 28 favor- 
able cases, the duration of the shortest was seven days. The remainder 
lasted from twelve days to six weeks, the most common period being 
betv^een three and four weeks. 

Complications and Sequels. — Dropsy. — This is one of the most fre- 
quent and important sequelae of the disease. We have already re- 
marked that in a considerable proportion of cases, the exact number 
apparently varying somewhat in different epidemics, the urine becomes 
albuminous during the stage of desquamation. This, however, is usu- 
ally transitory, and probably depends partly on the condition of the 
blood itself, and partly on renal congestion. But in some cases, owing 
to one of the causes to be mentioned hereafter, the albuminuria per-. 
sists, or if it has not been present or has disappeared, again makes its 
appearance; and the symptoms of acute nephritis develop themselves. 
Among these the most striking one is dropsj^, and, indeed, so promi- 
nent is it, as to have alone attracted attention for a long time, and onlj^ 
to have comparatively lately been associated with a lesion of the 
kidneys. 

Certainly, in the vast majority of cases, when dropsy appears as a 
sequel to scarlatina, the urine will be found to present all the charac- 
ters present in acute Bright's disease; and yet there are some high 
authorities (Simon, Becquerel, Philippe, Rayer) who assert that marked 
dropsy may occur without the slightest albuminuria. It is possible that 
some of these cases may be explicable by the fact that the urine has 
only been occasionally examined, and that albumen may have been 

46 



722 SCARLET FEVER. 

tcmporaril}^ present but have been overlooked; but it at present seems 
iitideniable, that, in some instances also, dropsy may appear without 
an}' abnormal condition of the urine whatever. It is probable that, in 
these cases, the dropsy depends upon an anaemic state of the blood, de- 
veloped during the course of the disease. 

The frequencj^ with which dropsy is developed, varies greatly in dif- 
ferent epidemics and in different forms of scarlatina. It occurred in a 
fifth of the cases of MM. Eilliet and Barthez, and in 31 of the 274, or 
in about a ninth, of those observed by ourselves. It occurs generally 
in the coui-se of the second or third week of the disease, and during 
the process of desquamation. It is thought to follow cases of moderate 
eeverit}^ much more frequently than those of a cgrave character. Dr. 
Tweedie states that it has never been observed to succeed a malignant 
attack. This does not, however, accord with our own experience, since 
of the 31 examples that we have seen, 8 occurred in grave cases of the 
disease. Still it may be said on the whole, that the susceptibility to 
renal disease bears an inverse proportion to the activity and complete 
development of the symptoms of scarlatina. The effusion may attack 
any one of the cavities or the cellular tissue of the body, or all at once. 
The most common form in which it appears is anasarca, after which 
the most frequent are, in the order in which they are mentioned, 
oedema of the lung, hydrothorax, ascites, and hydropericardium. 

The exciting cause of the dropsj^ is generally believed to be cold, con- 
tracted usually by exposure to air and moisture at too early a period. 
We have rarely known it to occur when the patient has been confined 
to the chamber or house until after the twenty-first day ; while, on the 
other hand, we have seen it to follow immediately upon a ride in cool 
weather on the fourteenth da}', the child having apparently been con- 
valescent for several days before. We have known it to occur also 
when the child has been allowed to run through the house exposed to 
draughts from open doors and windows. 

We have been able, in a number of instances, to trace it directly and 
obviously to cold. Thus, in one wary marked example, a boy between 
six and seven years old had had a mild attack of the disease, and was 
60 entirely recovered that we ceased our visits on the tenth day, leav- 
ing strict injunctions with the mother as to the necessity of confining 
the child to the house for at least ten days longer. On the fourteenth 
day, he was allowed to sit for fifteen minutes, late in the afternoon of 
a cool April day, on the marble front-door step. He was seized that 
night with fever and vomiting, had anasarca next day, and, during an 
illness of two weeks, had dropsy of the pericardium, effusion into the 
right pleural sac, ascites, and some signs of uraemia. In another case, 
a bo}' eleven years old had recovered entirely of a mild attack. He 
slept in a room heated b}' a stove. On the nineteenth day, the weather 
being cold, he got up earl}- in the morning to light the fire which had 
gone out accidentally. He was attacked that day wuth bronchitis, and 
was, on the following da}^ anasarcous. In another instance, anasarca 
was produced at the end of the third week, the child being quite well 



SEQUELS — DROPSY. 723 

previonsly, bj' his being taken into a cold room to sleep. We could 
cite other instances of the same kind, but these are enough. It it suf- 
ficient to say that in a large majority of the cases that we have seen, it 
has manifestly and obviously followed improper exposure during the 
second or third week. In a few cases, however, it has come on with- 
out anj' imprudence whatever, and we have been entirely unable to as- 
certain the cause. 

Kor can it 3^et be asserted positively that the action of cold will fre- 
quently cause dropsy unless the urine have been previously albumi- 
nous: although it is undoubted that when albuminuria is present, any 
ira])rudent exposure will insure the occurrence of dropsy. 

We are in the habit now of always directing the mother or nurse to 
keep the patient confined to the chamber for four weeks from the onset 
of the disease, or, if it be allowed to run through the house, to take 
care to have it well clothed, and to keep the windows and doors care- 
fully closed should the weather be cold or cloudy. This direction is 
one of the most important to be given in the course of the disease. It 
ought to be insisted upon in all and every case, occurring in the cool 
season of the year. 

The question was formerly much discussed, whether the condition of 
the kidney which accompanies scarlatinal dropsy was one of the forms 
of renal disease known as Bright's disease. Dr. Johnson suggested 
that it was a peculiar affection of these organs, characterized b}^ a des- 
quamation of the epithelium of the tubules, for which he proposed the 
name of desquamative nephritis. Eecent observations have, however, 
shown that there is in reality nothing specific in the lesion, but that it 
is identical with other cases of renal catarrh or tubal nephritis, to use 
the excellent name bestowed by Dickinson, occurring from whatsoever 
cause. Indeed, it may be said that in almost 75 per cent, of all cases 
of chronic renal disease in children, the cause of the affection has been 
scarlatina^ and the form of the lesion is that which we have above men- 
tioned. 

Various causes have been assigned for the frequent development of 
tubal nephritis in the course of scarlatina. Thus it has been supposed 
that the affection of the kidneys resulted from inaction of the skin, 
owing to the intense congestion which attends the eruption; but clin- 
ical experience shows that it is precisely in the cases where the affec- 
tion of the skin is most intense that the kidneys are least disposed to 
disease. It would rather appear that when the action of the virus is 
not fully determined to the surface, there is violent congestion of the 
kidneys established, which, especially when the patient is exposed to 
the action of cold, may result in the development of tubal nephritis. 

Morbid Anatomy of the Kidneys. — When death occurs in the acute stage 
of the renal disease, the kidnej'S are found enlarged and very heavy. 
The surface is smooth and injected; on section, the organ drips with 
blood; the Malpighian bodies are congested, and appear as red dots; 
and the vessels of the cortex and cones are gorged with blood. The 
tubules are distended with granular epithelium, granular matter, or 



724 SCAKLET FEVER. 

fibrinous pings. The cortex appears coarse-grained, and presents inter- 
mino'led dots or streaks of red and buff color. In the more chronic 
form of the disease, the kidnej^ is also much enlarged and very heavy; 
its surface smooth, and pale, or dotted with congested stellate vessels. 
The capsule is not thickened, and is readily removed. On section, very 
little blood escapes; the cones retain their pinkish or red color.; while 
the cortex is coarse-grained, thickened, and of a peculiar opaque white 
color. The Malpighian bodies may be distended, owing to obstruction 
to the escape of the blood. The principal lesion, however, is still found 
w4thin the tubules, which are stuffed with epithelial cells, or with gran- 
ular matter resulting from their disintegration ; occasionally, clear fib- 
rinous plugs are also seen occupying their calibre. It frequently hap- 
pens that the epithelium undergoes fatty degeneration, and when this 
is marked, the cortex acquires a yellowish tint. According to Dickin- 
son, there is less tendency to this change in cases of tubal nephritis 
following scarlatina than after other causes; a circumstance which he 
thinks may possibl}^ account for the comparatively curable nature of 
scarlatinal dropsy. 

The dropsical symptoms usuall}^ show themselves in the third or fourth 
week of the disease, and are generally preceded for a iQW days by albu- 
minuria. In most of the cases that we have seen they occurred in the 
third week, but they sometimes appear at the end of the second, and 
sometimes not until the fourth week. In one case they showed them- 
selves first on the thirtieth day, after the child had been exposed to 
too cool a temperature in an insufficiently warmed room. They occur, 
therefore, as a general rule, during the stage of desquamation. The 
attack is sometimes very sudden, but in most instances it is slow and 
gradual. The effusion is not commonly the first symptom observed. On 
the contrary, the drops}' is almost always preceded for one or two days 
by the signs of a more or less considerable constitutional disturbance. 
The patient has usually passed safely through the eruptive stage of the 
fever, and has been considered for several days as convalescent, for, as 
we have alread}' remarked, the dropsical affection is much more rare 
after grave than after mild cases. The child has perhaps been running 
about the house, or it has even been oat, the parents supposing, unless 
warned by the ph^'sician, from the disappearance of the fever and other 
symptoms of illness, and from the return of appetite and gayety, that 
complete recovery has taken place. But, either after some exposure, 
or sometimes without any appreciable cause, the child becomes drooping, 
languid, and irritable, or uneasy, peevish, and restless. Simultaneously 
with or very soon after these symptoms, fever sets in; the skin be- 
comes dry and heated, and there is usually an elevation of the tem- 
perature to the extent of 4° or 5°; the pulse is frequent and hard, or 
it is frequent and jerking; the appetite is diminished or lost, and there 
is more or less thirst; the bowels are generally constipated; the urine 
is usually diminished; and there is not unfrequently some nausea or 
vomiting, and complaints of headache. 

The symptoms which precede the appearance of the effusion are not 



SEQUELS — DKOPSY. 725 

alwavs, however, so marked, while in other instances they are scarcely 
noticeable, and yet the effusion may take place suddenly, and, affect- 
inijthe subcutaneous cellular tissue and different internal organs simul- 
taneously, may cause a fatal termination with frightful rapidity. 

The effusion usually commences in the face, which becomes slightly 
swollen. The amount of the effusion is sometimes very slight, leaving 
us in doubt even whether there is really any or not. The swelling is 
most marked about the eyelids, which look puffed, and it may be con- 
fined entirely to them, or, at least, it may be only in them that we can 
feel sure of its existence. From the face it extends to the hands and 
feet, and either remains limited to these parts, or spreads over the 
whole surface, and gradually or rapidly to the internal organs. The 
skin over the parts in which the effusion has taken place is firm, hard, 
and elastic to the touch ; it does not generally pit, at least not in the 
early stage, and it is of a dull white color. 

In very mild cases the constitutional disturbance is usually but slight, 
and the effusion may be so small in such instances, as to leave us in 
doubt as to the cause of the sickness. Generally, however, w^e have 
been able to determine the cause of the fever by a careful examination 
of the face, and particularly of the eyelids, which look a little swelled 
and distended, and by the presence of a slight puffiness or cushiony ap- 
pearance of the backs of the hands and feet. In such cases the general 
sj'mptoms usually pass away after a few days; the urinary secretion, 
which had been diminished in quantity and of a deeper color than nat- 
ural, becomes again healthy; the anasarca disappears, and the child 
returns to its ordinary condition. In more severe cases the general 
symptoms are all more marked; the anasarca is more extensive and 
the swelling more considerable; the child, if old enough to describe its 
sensations, complains of pain in the back, and the lumbar region is ten- 
der to the touch; the urine exhibits much more marked changes in its 
character; but stilly unless some important internal cavity be attacked, 
the symptoms diminish after a week or ten days, and the child recovers 
gradually. In still more violent cases, the amount of the effusion is very 
large indeed, the face is disfigured by the swelling, the limbs are largely 
distended, the cellular tissue of the trunk of the body is infiltrated, the 
quantity of urine discharged is very small or the secretion is arrested 
entirely for one or several days, and the fever is high. If the disease 
is not removed, the effusion may extend to the internal organs: to the 
lung, producing oedema of that organ, to the pleural sac, causing hydro- 
thorax, to the pericardium, to the peritoneal cavity, or to the brain. 
Death may occur in these violent cases from asphj^xia occasioned by 
oedema of the lung, by hj^drothorax, or by the obstacle to the circula- 
tion caused by the presence of the effusion in the pericardium; from 
hydrocephalus, or, finally, the patient may sink into a comatose state 
like tliat which often precedes the fatal termination of Bright's disease 
in the adult, and due, like that, to uraemia. 

It sometimes happens, as was stated above, that death occurs with 
very great rapidity. MM. Guersant and Blache have known it to end 



726 SCARLET FEVER. 

fatally in twelve, fourteen, and thirty-six hours. In a case that came 
under our own observation in consultation, a child between one and 
two years old, who had had a very mild attack of scarlet fever, was 
seized suddenly towards the end of the third Aveek, after it was sup- 
posed to be quite well, and after exposure to draughts of cold air in 
the lower room of a small house, with vomiting, and shortly afterwards 
with convulsions and coma, which terminated fatally in thirty -six hours. 
In another case, in a boy between thirteen and fourteen years old, who 
had had a mild but well-marked attack, and who had convalesced, and 
been out of bed for a few days, fever with slight headache, and dim- 
inution of the urine, came on at the end of the second week. After 
two days of slight ailment, without any signs of anasarca, he suddenly, 
without any warning, fell into violent convulsions, which Avere repeated 
frequently, with lulls of imperfect consciousness, for a few hours. 
After twelve hours he became completely comatose, Avith occasional 
convulsive seizures, and died at the end of eight hours more. 

According to Gee (loc. cif.), uriiemic convulsions and coma are not 
frequent in the course of scarlatinal dropsy, nor are they of such fatal 
import as in acute Bright's disease in the adult. 

The symptoms Avhich mark the occurrence of internal effusion Avill 
depend of course upon the part attacked. In one case they Avill be 
those of oedema of the lung, in another those of hydrothorax, and in 
another those of hydropericardium or ascites. 

Urine. — The particular condition of the urinary function is next to be 
described. It has already been stated that the amount of urine secreted 
is less than natural during the earl}^ period of the dropsical attack. 
But, Avhile this is true, it ought to be observed that the patient often 
voids the secretion more fj-equently than usual. There is in fact mic- 
turition, a symptom occasioned no doubt hj the irritating character of 
the urine, Avhich causes the bladder to contract and expel that fluid so 
soon as even a small quantity collects. The diminution in the amount 
of the secretion is usually a very marked symptom. It is sometimes 
aln-iost or even entirely suppressed for a considerable period. In one 
case that occurred to one of ourselves, in a boy between one and two 
years old, there Avas no discharge whatever for a period of thirtj^-six 
hours. During this time there was no distension of the bladder, as Ave 
ascertained this point by careful palpation and percussion. In another 
case, which occurred in a girl between three and four years old, and 
Avho Avas nursed by the grandmother, one of the most accurate, reli- 
able, and experienced nurses in the city, Ave Avere assured that there 
Avas no discharge whatever of urine for five days in succession. Dur- 
ing this suppression there Avas no accumulation in the bladder. On 
the contrary, the hj'pogastric region was flat, depress! ble, and sonorous 
on percussion. The patient Avas very ill during all this time. She was 
feverish and passed nearlj- the Avhole time in a semi-comatose state, 
but could be roused Avith much effort, so as to shoAv some intelligence; 
Bhe rejected by vomiting almost everj'thing that Avas given her, and 
complained Avhen aroused of severe headache. She had no convulsions 



SEQUELS — DROPSY — CONDITION OF THE URINE. 727 

nor anv convulsive movements, and finallj^ recovered as the kidneys 
regained gradually their secretory function. In many other cases that 
have come under our observation, especially those which we have seen 
in latter j^ears, when we have watched this symptom more carefully, 
the diminution of the urine has been very great, so much so as to con- 
stitnte a most marked and reliable sj-^mptora. 

In mild cases, when the diminution is not very marked, the urine is 
of a deeper color than natural, but retains its transparency wlien fii'st 
voided. It is apt, however, to become turbid on cooling, and to deposit 
a more or less abundant precipitate of urates. Its reaction is acid ; its 
specific gravity increased in proportion to the concentration ; and urea 
and the chlorides are much diminished. Albumen is present, and micro- 
scopic examination shows epithelial or hyaline casts of the renal tubules, 
renal epithelium, and blood-globules. In more severe cases, the urine 
is very much diminished in quantity, the color is either a very dark 
red, or has a blackish or brovrnish tint, or is like smoke or soot; the 
specific gravity is very high; the amount of albumen large, and the 
precipitate contains many casts and blood-globules, mixed with abun- 
dant urates. 

The amounts of albumen aud blood bear no definite relation to each 
other; in some cases^ the albunien ma}" be abundant without an}" blood 
being present; while in other cases, with' a large precipitate of blood- 
globules, the urine may contain but a moderate amount of albumen. 

Basham calls attention to the occasional development of a bluish-green, 
and subsequently greenish-black color, on the addition of nitric acid to 
the heated urine, as a sign of very grave augury, being associated with 
extensive and advanced renal disease. 

The duration of this stage of diminution of urine varies greatly in 
different instances, and is, to a certain extent, indicative of the future 
progress of the case. It is succeeded by a stage in Vv^hich the urine be- 
comes abundant, even exceeding the normal amount, the specific gravity 
falls, and the urea and chlorides return to the normal figure, but albu- 
men is still present, the smoky color is apt to persist, and the precipi- 
tate which forms on standing contains renal epithelium, blood-globules, 
and granular or epithelial casts. 

In favorable cases, the smokiness and albumen now gradually disap- 
pear, the urine often continuing for a little while to be secreted in ex- 
cessive quantity; but in other cases, and unfortunately they are but 
too frequent, the albumen persists, and the urine assumes the characters 
indicative of chronic Bright's disease. 

The form which the dropsy takes varies greatly in different cases, 
and seems to depend on inappreciable causes. Of the 29 cases that we 
have met with, in which its distribution was noted, anasarca alone was 
present in 22. In 1, there was extensive anasarca, hydrothorax of the 
right side, hydropericardium, and ascites. In 5, grave cerebral symp- 
toms, probably ursemic in character, were present; and in 4 of tliese 
anasarca also existed. In 1 there were also hydrocephaloid symptoms, 
but of much less violent form. 

Eecent researches have established the fact that most of the cases for- 



728 SCARLET FEVER. 

merlj^reixarded as acute hydrocephalus are in reality due to the poisoned, 
state of the blood, the so-called ursemia, so familiar to all, that it is 
merely necessary to allude to it in this place. 

The degree of danger to be appreliended from this dropsical compli- 
cation depends upon the form which it assumes. M. Cazenave (loc.cit., 
p. 52) says that there is no danger from it so long as it remains confined 
to the subcutaneous cellular tissue; and this is probably true. When, 
however, it attacks the serous cavities, or becomes associated with 
cerebral symptoms, due to the retention of urea and other excremen- 
titious matters in the system, it is exceedingly dangerous. Dr. Wood 
(Pract. of Med.^ vol. i, p. 403) says that he has seen but one fatal case 
of scarlatinal dropsy, and in that the heart was diseased. Of the 29 
cases that we have had und^r charge, 6 were fatal. Of the 22 cases in 
which the effusion was anasarcous alone, but 1 was fatal. All of the 
5 in which well-marked hydrocephaloid symptoms, due to uraemia, 
occurred in connection with anasarca, ended fatallj^. In one other case, 
which ended favorably, there were mild ursemic symptoms present. 
In the case above adverted to, in which hydrothorax, hydropericar- 
dium, and ascites were added to the anasarca, the patient recovered 
after a long and severe illness. 

In addition to the cases of dropsy and ursemia just referred to^ and 
which all occurred in our own practice, we have seen two examples of 
scarlatinous dropsy with uremic sj'mptoms in consultation, one of which 
came on very suddenly in a young child, and proved fatal in thirty-six 
hours, while the other terminated favorably after a severe illness of 
nearly two weeks. In the latter case, the patient, a girl, between three 
and four years old, was in a semi-comatose state for a week, with fever, 
excessive irritability of the stomachy and complaints of headache. For 
a period of five days the urine was entirely suppressed, not a drop 
having been voided during all that time, at least with the knowledge 
of the nurse, who was a most accurate and competent j^erson. In a 
third case, seen in consultation, the child died after ten days' violent 
illness, with ascites, extensive hydrothorax, and dropsy of the pericar- 
dium. Lastly, in a fourth case, also seen in consultation, the patient, 
an infant in its second }'ear, after having had anasarca for a few days, 
became drowsy, had frequent vomiting and heat of head, but recovered 
under the use of active counter-irritation over the back and diuretics. 
It would seem to be much more dangerous in the Parisian hospitals than 
in private practice in this country, since MM. Guersant and Blache 
speak of having seen it prove fatal in twelve, fourteen, and thirty-six 
hours, after one or two weeks, or even two or three months; and MM. 
Eilliet and Barthez refer to it as often proving fatal. 

Diarrhoea is not an uncommon accident in the disease. It generally 
depends on simple functional derangement of the bowels. In some cases, 
however, it is so severe or long-continued as to constitute a serious com- 
plication. Under these circumstances, it depends on follicular entero- 
colitis, or slight erythematous inflammation of the intestinal mucous 
membrane. 



SEQUELS — ANATOMICAL LESIONS. 729 

In some cases, chronic angina remains after the subsidence of the dis- 
ease; so, too, coryza may persist, even taking the form of ozsena. 

Otorrhoea is a not infrequent sequel, and when following angina, and 
due to the extension of inflammation up the Eustachian tube, may be 
associated with permanent deafness, necrosis of the temporal bone, 
facial palsy, and even abscess of the brain. 

Occasionally during the desquamative period, a painful swelling of 
the joints appears, attended with a renewal of the fever and, frequently, 
with sweating. This form of rheumatism is in all probabilit}' connected 
with the imperfect excretion of some excrementitious substance, owing 
to the state of the various emunctories. In rather rare cases, the in- 
flammation of the joint runs on to fatal suppuration. 

Bronchitis and pneumonia are rare. Inflammation of the serous mem- 
branes is more common, occasioning in some cases the dropsical effusions 
which have already been treated of It is in most cases connected either 
with ]-enal disease or with the form of rheumatism above described. 
The pleura is more frequently affected than any other of the serous 
membranes; and not rarely the effusion becomes purulent. 

Inflammation of the investing or lining membrane of the heart also 
occasionall}' occurs. Thus, of 39 cases of endo- or pericarditis men- 
tioned by Dr. West, 6 could be traced to an attack of scarlatina. 

Peritonitis is much more rare, and the effusion here also is especially 
apt to be purulent. 

Scarlatina may be coincident with variola or measles. We have never 
seen it in connection with the former, but in two cases which came 
under our observation it was complicated with measles. 

Diphtheria has also been observed not very rarely, usually appearing 
during convalescence. In a considerable number of cases, scarlatina 
has been noticed in the course of typhoid fever. 

In some rare cases, as in the one detailed under the head of progno- 
sis, more or less complete paralysis ensues during the convalescence 
from scarlatina. 

Tuberculosis is not nearly so apt to be developed after scarlatina as 
after either rubeola or typhoid fever. 

Anatomical Lesions. — The eruption sometimes disappears entirely 
after death, and on other occasions assumes a deep livid or purple ap- 
pearance. The epidermis is generally loosened upon the integument, 
so as to be peeled off with great facility. The most important lesions, 
and those which seem to belong to the nature of the disease independent 
of complications, are the altered condition of the blood, and congestions 
of different parts of the body, particularly^ the brain, serous membranes, 
kidneys, spleen, glands of Peyer, and intestinal follicles. We have 
already alluded to the fact that, even when the cerebral s^^mptoms have 
been most severe, and we might expect to find evidences of violent in- 
flammation of the brain, nothing is observed after death, in the majority 
of cases, but congestion of the large veins and sinuses of the brain, of 
the pia mater, or of the cerebral substance. There is rarely any un- 
natural amount of serous effusion into the ventricles, or meshes of the 
pia mater; and it is evident that the symptoms have been due entirely 



730 SCARLET FEVER. 

to the vitiated condition of the blood. Nevertheless, effusions within 
the cranium may exist, in some few cases, as has been already stated 
in the remarks upon h^'drocephalus. 

The resj^iratory organs are usually healthy, with the exception of 
conL''OStion and serous engorgement. 

According to the researches of Fenwick, Fox, and Murchison, it ap- 
pears that the entire gastro-intestinal mucous membrane is aifected in 
many cases of this disease. There is congestion of the subepithelial 
la^-crs, with excessive formation and subsequent desquamation of the 
epithelium. The gastric tubules are greath^ distended and obstructed 
by cells mixed Avith granular and fatty matters, and casts of their cali- 
bres are frequently found in the matters vomited or in the contents of 
the stomach after death. 

The condition of the skin resembles this closely, the rete mucosura 
being thickened, with a formation of numerous round nucleated cells, 
and the sudoriferous glands being often obstructed by the rapidh' formed 
cells. 

Tlie glands of Brunner and Peyer arc not unfrcquently enlarged, and 
the}' are sonietimes reddened or softened. In a smaller number of 
cases the mesenteric glands are slightlj' inflamed and increased in size, 
and the spleen is redder than usual or softened. These lesions have 
no necessary relation to the form of the disease, since they are often 
absent in tj'phoid cases, and present in those of a different type. 

Tlie kidnej's are healthy, with the exception of some degree of con- 
gestion, unless the case has been complicated with drops}:'. Under these 
circuni'^tances they usually present the characteristic lesions of tubal 
nephritis, which we have already described. 

The heart occasionally presents the results of inflammation of its 
lining or investing membrane; and in some cases its cavities contain 
firm white ante-mortem clots. 

The blood exhibits very different appearances in different cases. It 
is viscid or serous, dark colored or light, and fluid or coagulated, the 
clots being of variable color and density. The proportion of its con- 
stituent elements is changed. The fibrin maintains its usual relation to 
the mass of the fluid (3 parts in 1000), or it is very slightly augmented, 
while the quantity of the globules is increased to 136 or 146 parts, ac- 
cording to M. Andral, instead of 127, in 1000 parts. This increase in 
the proportion of flbrin may be in part the cause of the fibrinous depo- 
sitions which occasionally are found in the cavities of the heart, and 
appear to have been instrumental in causing death. 

In an article on " The Pathology of Scarlatina, and the relation be- 
tween Enteric and Scarlet Fevers" {Jled.-Chirurg. Trans., vol. Iv, p. 
103), Dr. John Harley, of London, reports thirty-six cases of scarlet 
fever, to show that the anatomical lesions of that disease are the same 
as those of typhoid fever in its early period, and that not unfrequently, 
scarlatina, when long continued, passes into enteric fever. After de- 
scribing these lesions, he says (p. 125): ''From this view our general 
conclusion as to the connection of scarlet fever and enteric fever is inevitable, 
viz., that the pathological changes accompanying an attack of scarlatina, in- 



ANATOMICAL LESIONS. 161 

chide all those of the first stage of enteric fever, and are so far identical 
with them. And it follows, therefore, that the transition from the former 
disease to the latter is nothing more than a natural pathological se- 
quence, readily determined b}' any cause which may increase the intes- 
tinal irritation." The italics are Dr. Barley's. 

We have, on a few rare occasions, known cases of scarlet fever in our 
private practice, where the disease has been prolonged beyond its usual 
period, to assume some of the phenomena of typhoid fever, but this 
occurrence has been so infrequent that we doubt Avh ether it ought to 
be regarded as the natural evolution of a pathological law connecting 
the two affections. That typhoid fever may attack a child just recov- 
ering from scarlet fever is as probable as that measles and scarlet fever 
may directly follow each other, or even coexist at the same moment. 
Of both of these accidental coincidences, we have seen a few well- 
marlvcd examples. Several of the cases described by Dr. Harle^^, in 
which typhoid fever certainly followed scarlet fever, occurred in patients 
admitted to hospitals. Five occurred in the London Fever Hospital, 
and in some of these the attacks of enteric fever began after full 
convalescence from scarlet fever; in one on the 28th day of convales- 
cence; in a second on the 31st day; in another on the 37th day; in 
another on the 32d day; and again on the 56th and 32d days. We 
would ask whether in such cases the sequent typhoid fever ought not 
to be explained as the result of fever-poison imbibed during the resi- 
dence in the wards of a fever-hospital. 

One very interesting fact observed by Dr. Harley, is the frequency 
with which he found fibrinous clots in the heart and great vessels, 
" during a pyrexial state, at any period of the disease. This," he states, 
"is the commonest cause of death during the early stage of scarlatina ; 
it is indicated during life by the reduction, often sudden, of a full pulse 
of about 120, to a dribble of 150 or 160 almost imperceptible impulses. 
The failure of the heart's action is commonly attended with orthopnoea 
and delirium from obstruction to the pulmonary and cerebral circula- 
tions. On opening the body before it has lost a degree of temperature, 
and while the hot blood is still fluid, the right heart will be found dis- 
tended, partly with dark fluid blood, which coagulates on exposure; and 
parti}', sometimes chiefly, by a large, firm, white, bifid clot continuous 
through the auriculo-ventricular opening. Each portion is interlaced 
with, and firmly adherent to the tendinous cords and outstanding mus- 
cular bands of the cavity in which it lies, and sends outwards a rope- 
like continuation, the one into the pulmonary artery, and the other 
into the superior cava. These processes not onl}^ occupy a large por- 
tion of the area of these tubes, but extend w^ith their branches, up- 
wards into the cranial cavity, and outwards into the lungs, whence 
they may often be withdrawn in ramifications up to the eighth degree, 
and eight or nine inches lono;. 

"The left heart was generally empty and firmly contracted; in one 
case (1) each cavity was occupied by a large fibrinous clot, that in the 
ventricle spreading into the brachio-cephalic vessels of the arch of the 



732 SCARLET FEVER. 

aorta, and that in the auricle sending large ramifying branches into 
the pulmonarj^ veins. In another case (12) the auricle was distended 
with dark softly-clotted blood." 

We desire to call attention to these facts, since we doubt not that 
they explain many of the cases of earlj^ death in this disease, in which 
all medical treatment has proved so futile, and also on account of the 
great interest of these observations in connection with the similar re- 
sults which have already been noted in diphtheria. 

Diagnosis, — It is impossible to distinguish scarlatina from the other 
eruptive fevers by the symptoms which precede the eruption. The 
onl}' signs upon which a diagnosis at that time might be grounded, are 
great frequency of pulse, which is characteristic of tliis disease, some 
soreness or redness of the fauces, and the prevalence of the disease in 
the community. Eut these are all exceedingly fallacious, and the ph}'- 
sician should be content to wait for the eruption before he ventures to 
speak with certainty. After the eruption has com.e out it can scarcely 
be mistaken for anything else, except it be roseola. 

From measles it may be distinguished by the differences in the pro- 
dromes, course, and eruption of the two affections. The prodromic 
stage of scarlatina rarely lasts more than twenty-four hours, and is very 
often much less; that of measles, on the contrary, is almost always 
from three to four days ; in scarlatina the rash appears suddenly, and 
often spreads over the whole body in a single day; in measles it appears 
on the face first and extends gradually to the rest of the surface, seldom 
reaching the hands and feet before the end of the second day; the 
eruption of measles occurs first in distinct j)apules, which coalesce and 
form patches of an irregular crescentic shape, while that of scarlatina 
is in the form of innumerable minute dots or puuctations, placed so 
closely together as to give to large portions of the surface a uniform 
color, like that produced by blushing. The color of the two eruptions 
is different, that of measles being dark like raspberry-juice, and that of 
scarlatina of a more or less bright scarlet tint. The presence of ca- 
tarrhal symptoms in measles, and their absence in scarlet fever: the 
absence of angina in the former disease, or its very slight character, 
and the severity of the throat affection in scarlatina; and lastly, the 
greater severity of the febrile symptoms, particularly the frequency of 
the pulse and the heat of skin in scarlatina, are other points of dif- 
ference which will assist in making the diagnosis, rarely, it seems to 
us, difficult, still more certain. A very great frequency of the pulse is 
one of the most unfailing symptoms of the early stage of scarlet fever. 
It almost always rans up to 140, 150, or 160, in young children, within 
the first twelve or twenty-four hours, and to 120, 130, 140, or higher, 
in those who are older. Nevertheless, this, like all other symptoms, is 
sometimes wanting. We have lately seen a boy, between five and six 
years old, with a marked but very safe attack of the disease, whose 
pulse ranged between 80 and 90 throughout the sickness. This was, 
however, the only case we have ever met with, in which the pulse re- 
mained so little disturbed. 

It is sometimes very difficult to determine with precision between 



DIAGNOSIS — PROaNOSIS. 733 

roseola and scarlet fevei'. By the eruption alone, we believe it to be 
often impossible. We have seen quite a number of cases in which the 
eruption of roseola resembled so closely that of scarlet fever, that we 
should have been obliged to confess our inability to make the distinc- 
tion had it not been for the other symptoms, and particular! 3^ the fre- 
quency of the circulation, the heat of the skin, and the throat sj^mp- 
toms. The most important differential symptoms are the tint of the 
eruption, which in roseola is rose-colored, in scarlet fever bright-red or 
scarlet; the characters of the patches of eruption, which are more reg- 
ular in shape, but of much smaller size in roseola than in scarlet fever; 
the absence or very slight degree of anginose inflammation in roseola; 
and, what is decidedly the most important of all, the very much slighter 
degree of febrile reaction in roseola, in which the pulse, instead of 
being doubled in frequency as it is in scarlet fever, is scarcely above 
its natural rate, and in which the heat of skin is but little above the 
standard of health. Moreover, roseola is generally of shorter duration, 
and is a milder affection, and therefore accompanied by far less fever 
and general disturbance of the constitution. 

Diphtheria occasionally resembles scarlatina to so great an extent, as 
to have even led some observers to consider them identical. Thus, 
there is in diphtheria a pseudo-membranous angina, with swelling of 
the cervical glands, and at times albuminuria, and even an erythema- 
tous rash. We have elsewhere (see article on diphtheria) given at 
length the differential diagnosis between these affections, and will 
here merely call attention to the fact that the rash is a rare exception 
in diphtheria, and is a mere uniform erythematous redness; that even 
when albuminuria is present, the urine does not present the other char- 
acters noted in scarlatina; and that the condition of the fauces in the 
two diseases is somewhat different. There is, further, a wide differ- 
ence in the sequelae of the disease; and, finally, they do not exercise 
any protective power whatever against each other. 
' There is a form of disease known as rubeola notha, epidemic roseola, 
rosalia (Richardson), in which there are some of the symptoms of both 
measles and scarlatina; the eruption appearing on the second or third 
day, at first resembling that of measles, but becoming soon more like 
that of scarlatina. Corj^za and angina may both be present, and there 
is subsequent desquamation. Some authorities regard this as a union 
of the poisons of measles and scarlatina, while others consider it a 
separate disease, because epidemics of it occur when neither measles 
nor scarlatina are prevailing. Previous attacks of these latter do not 
protect against it. In an extensive epidemic in the lower part of this 
city, which appeared to be of this nature, not a single case, of the 
numbers which came under our observation, was followed by any of the 
sequelae of either measles or scarlatina. 

Prognosis. — It is impossible to obtain a useful average mortality of 
scarlet fever, since the disease varies so greatly in different epidemics, 
and under different h3'gienic conditions, that the results obtained dur- 
ing one period are inapplicable to cases observed at another. This is 
proved by the experience of almost every physician, and b}^ the evi- 



734 SCARLET FEVER. 

den CO of many writers. It is proved, also, by the following facts : M. 
Gueretin {Joe. cit., p. 283) states that the mortality in the epidemic ob- 
served by him was about 1 in 12; of 99 cases, 8 died. Mj\i. Rilliet and 
Barthcz lost a little more than half their cases; of 87, the total, 46 were 
fatal. These cases, let it be remarked, however, occurred in the Hos- 
pital for Children in Paris, which will account for the heavy fatality. 
The degree, however, to which the mortality may vary in the same 
place and under the same plan of treatment, is shown by the fact, men- 
tioned by Hillier, that in the course of eleven j^ears the annual mortal- 
ity from scarlet fever in the London Fever Hospital, varied from 2.5 
per cent, to 16.5 per cent. ; and in the Hospital for Sick Children in 
London, from 9 to 31 per cent. Of the 274 cases that we have ob- 
served, 31, or rather more than one-ninth, were fatal. Of the 274 cases. 
104 occurred between 1819 and 1853, and in those the mortality was 
much smaller than in those which occurred prior to that j^ear. Of 104, 
11 were fatal, or about one in nine and a half. Seventy-eight cases oc- 
curred between 1853 and the spring of 1857. Of these 78, only 4, or 
one in twelve, were fatal. Of 81 cases observed previous to 1849, 13, 
or about one in six, proved fatal. Of 11 cases occurring in 1872-3, 3 
proved fiital. The mortality met with by ourselves in private prac- 
tice has greatly varied, therefore, in different series of years. In one 
series it was 1 in 6^ in another 1 in 9J, and in a third 1 in 12. Lastly, 
to show the influence of the epidemic type upon the mortalit}^ still more 
clearly, we may state that of the last series of cases observed, 78 in 
number, 43 occurred during the epidemic which lasted from the sum- 
mer of 1856 to the spring of 1857, and of these only 3, or 1 in 14, died. 
The prognosis must be based, therefore, in part on the character of 
the epidemic prevailing at the time. It must depend, also, on the nature 
of the case. Mild and regular cases are rarely fatal. Of 206 mild cases 
that have been under our care, only three proved fatal. One of these 
would probably not have so terminated had it not been for the impru- 
dence of the nurse. This was, in fact, the case of a young child who 
had recovered from the eruptive stage of the disease, but whom the 
nurse carried out of the room in the second week, notwithstanding ex- 
press directions given her to the contrary. The child took cold and 
was seized with catarrh and slight anasarca; on the fifteenth day ursemic 
symptoms set in, and he died on the seventeenth day, comatose, and 
with convulsive movements of different parts of the body. The second 
case was that of the boy thirteen years old, already described, who died 
with sudden hydrocephaloid symptoms, at the end of the second week. 
The third fatal case occurred in a girl between eight and nine years 
old, who died suddenly at the end of six weeks. The patient had con- 
valesced sufficiently to have been out several times, but remained very 
hydricmic and weak. After being much fatigued one afternoon by 
playing with some little friends, she was seized next day with vomiting, 
and soon after with great difficulty of breathing and extremely rapid 
and feeble action of the heart. These symptoms increased on the fol- 
lowing day. The dyspnoea was most severe, and was attended with 



PROGNOSIS. 735 

cyanotic color of the bands and face, and with cold colliquative sweats. 
The liino-s were free, there was no cough, and auscultation revealed no 
pericardial lesion. Death occurred suddenl}' at the end of a day and a 
half. ]S"o post-mortem vras made, owing to circumstances that could 
not be controlled. Our own opinion was, and is, that the death was 
caused hy a coagulum in the heart. 

Grave cases of scarlet fever are always, on the contrary, exceedingly 
dangerous : thus of 61 cases of this kind that we have had under charge, 
28^ or nearly a half, were fatal. In order to render the description of 
the symptoms of this class of cases more clear, we divided them into 
two groups; one, in which the onset of the disease is instantaneous and 
most violent, being characterized by excessive disturbance of the nerv- 
ous sj^stem, taking the form usually of convulsions, but sometimes only 
of profound coma; and a second, in which the symptoms of the onset, 
though severe enough usually from the first to mark the character of 
the case as grave, are less violent than in the first group, and especially 
not marked by the occurrence of convulsive phenomena. Of 18 cases 
belonging to the first group, 13 died ; while of 43 belonging to the second, 
15 died. Violent nervous symptoms occuri'ing early in scarlet fever 
augur, therefore, great danger to the patient, since of 18 cases in which 
they were present, 13 died, whilst of 43 in which they were more moder- 
ate, though still marked and severe, only 15 died. 

The character of the nervous symptoms is, therefore, all-important in 
the determination of the prognosis, as the probable termination of the 
case is to be foretold more certainly by a just appreciation of these par- 
ticular phenomena of the disease, than by any other means. Excessive 
jactitation or irritability, delirium, coma, and the hydrocephalic cries, 
are all unfavorable symptoms, but not in the same degree as are those 
connected with the locomotor apparatus. MM. Eilliet and Barthez 
state that they have seen recoveries take place in cases in which the 
intelligence of the patient had been very much disordered, while of 
those who ^'during the first fifteen days of scarlatina, were taken with 
convulsions, convulsive movements, contractions, in a word, any symp- 
toms affecting the locomotor apparatus, all, without exception, died/' 
This does not accord exactly with our own experience, though nearly 
enough so to show how exceedingly dangerous are the sj'mptoms just 
enumerated when they occur early in the disease. General convulsions 
occurred on the first day of the disease in 9 of the 61 grave cases observed 
by ourselves, and of these not one terminated fortunatelj^; in four they 
occurred on the second day, and of these three recovered and one died; 
in one they occurred on the ninth daj", and this patient also recovei-ed ; 
in another case there were no general convulsions, but on the first day 
there were automatic motions, with involuntary extensor motions of the 
arms and fingers, and on the second da}' strabismus, with a continuation 
of the automatic motions. This case proved fatal. Of the 15 cases, there- 
fore, in which marked disturbances of the muscular system occurred, only 
4 ended favorably. Of 10 subjects in which the convulsive phenomena 
occurred on the first day of the disease not one escaped. Of 5 subjects 



736 SCARLET EEVER. 

in whom these symptoms appeared on or after the second day, 4 escaped. 
One of the favorable cases occurred in a boy seven years old, who had a 
general convulsion, lasting several minutes, on the second day of the 
attack; this was followed by delirium and coma alternately, but no re- 
turn of the convulsions. The case was a most violent one, and lasted six 
weeks, leaving the child at the termination very deaf, but otherwise in 
o-ood health. The second case occurred in a child five months old. The 

to 

convulsive symptoms appeared on the ninth day, and consisted of stra- 
bismus, spasmodic retraction of the head, and occasional slight spasms 
of the limbs. They alternated with coma, and disappeared on the tenth 
day, until the seventeenth and eighteenth, when the strabismus reap- 
peared. The child recovered perfectly. The third was that of a very 
healthy and vigorous boy between eight and nine years old, "who, on 
the second day of an attack w^hich had begun like a severe cholera 
morbus, had, twice, fits of insensibility, with stiffening of the extensor 
muscles of the fingers, rigid contractions of the flexors of the arms, and 
spasms of the eyeballs. This case proved afterwards very violent, so 
that the patient nearly died on the fifth day, with asphyctic symptoms 
caused by very great swelling of the tonsils and fauces, and enormous 
enlargement of the external cervical lymphatic glands, complicated 
moreover with extensive acute oedema about the chin and front of the 
neck. These symptoms were followed again by diphtheritic deposit 
covering the whole of the pharynx. He finally, however, recovered 
perfectly. The fourth case was that of a boy between five and six years 
old, who, on the second day, had an attack of general convulsions, 
w^hich were repeated frequently on the third day. This patient con- 
tinued very ill for several days, and when, at last, he began to improve 
somewhat in the middle of the second week, it was found that he had 
lost entirely the powder of speech, and all control over nearly the whole 
of the locomotor apparatus of the body. He could neither lift his head 
nor turn it; the legs were immovable; the hands were perfectly help- 
less. The only motion that remained was a jerking, apparently almost 
automatic, movement of the arms upon the shoulders, and the forearms 
upon the arms. But even these were most irregular, and badly co-or- 
dinated. He was very much in the condition of a new-born child. It 
was very difficult to ascertain what the condition of his senses was; 
but after a short time we Avere able to satisfy ourselves that he saw 
and heard, and only after many weeks was he able to hold a very light 
object in his fingers, then to move his head from side to side, and at a 
still later period to hold it up. At the end of about two months, he 
could sit in a chair when once placed in it, but could not sit on the floor 
unsupported. At the end of three months he was learning to walk by 
being held up by the arms. He had never spoken a word. The only 
approach to anything like articulation was his ability to hum a low 
gentle musical note; his intellectual faculties, as exhibited by signs, had 
regained their natural condition at this time. At the end of ten months, 
he could speak intelligibly some three or four words. The fifth case was 
that of a male infant, nine months old, who, on the second day, had 



PROGNOSIS — TREATMENT. 737 

severe general convulsions, followed by veiy deep drowsiness. The 
eruption became intense, and, on the third day, the convulsive symp- 
toms recurred from time to tijne, but with less violence. On the fourth 
day he seemed somewhat better, but on the fifth very severe anginose 
symptoms set in, and he died. 

Again, in 20 of the 61 grave cases, severe and more or less prolonged 
delirium or coma occurred, and of these 14 died. We may conchide, 
therefore, that convulsive symptoms appearing early in scarlet fever 
indicate a highly dangerous and, in all probability, a fatal attack; while 
severe, and especially prolonged delirium or coma, are also extremely 
unfavorable symptoms, but somewhat less so than are those of a con- 
vulsive character. 

Other unfavorable symptoms are : extremely frequent or very vio- 
lent pulse; intense heat or unnatural coolness of the skin; persistently 
elevated temperature after deflorescence ; deficiency or sudden disap- 
pearance of the eruj)tiou ; a livid or purple tint of the eruption ; slow 
and imperfect capillary circulation, as ascertained by pressure; the ap- 
pearance of petechise, ecchymoses, or hemorrhages; violent vomiting 
and colliquative diarrhoea; great violence of the throat-affection, whether 
from tumefaction, great abundance of pseudo-membranous exudation, 
or disposition to ulceration and sloughing; and lastly, severe coryzaor 
otorrhoea. A disposition to a typhoid state, indicated by dulness of 
the intelligence, dusky hue of the skin, frequent and feeble pulse, dry, 
brown tongue, sordes on the teeth, meteorism, and disposition to diar- 
rhoea, is always dangerous. 

When, on the contrary, the fever is moderate, the cerebral symptoms 
absent or very slight, and the eruption regular, and of a bright tint; 
when there is no disposition to typhoid symptoms; when the throat- 
affection is mild, and the disease pursues a regular, uniform course, we 
have every reason to expect a favorable termination in a large majority 
of the cases. 

In addition to these remarks it may be said that neither age, sex, nor 
social position influence the prognosis. A delicate constitution does 
not seem to predispose to a violent attack of scarlatina, and indeed, 
many of the most malignant cases occur in very robust children ; but, 
on the other hand, it has been noticed that in certain families there 
exists a strong tendency for the disease to assume a grave and fatal 
form. 

Treatment. — Hygienic treatment. — In all cases of the disease, whether 
of the mild or grave kind, the strictest attention should be paid to the 
hygienic condition of the patient. The room in which the child is 
placed ought to be, if possible, large, and at all events well ventilated. 
The temperature in winter should be carefully attended to. We usu- 
ally direct it to be kept at from 68° to 70° F., during the early stages 
of the disease, unless the fever is violent and the child complains of 
heat, in which case it may be allowed to fall to 66°, or even 62°. The 
clothing ought to be moderate, not enough to increase the heat of the 
skin, nor yet so little as to endanger chilliness. During the latter 

47 



738 SCARLET FEVER. 

stages of the disease, when the fever has subsided, and particularly 
when the heat of the skin has fallen, the temperature of the chamber 
ought to be kept, as a general rule, at from 68° to 70°, and, when the 
child is pale, weak, and chilly, it may be maintained with great pro- 
priety at 72°. 

One of the most important points in the treatment of scarlet fever is, 
undoubtedly, the management of the patient during the convalescence, 
and especially during the desquamative period. It is during this period 
that the child is liable, as we have already shown in our account of the 
different complications and sequelae of the disease, to dropsy, which is 
the most frequent, and at the same time the most dangerous accident 
to which the patient is exposed. There can be no doubt, we think, 
from the opinions expressed by various writers, and also from our own 
experience, that the most common cause of this accident is exposure 
to cold. Chilling of the body, no matter how produced, is exceedingly 
apt, when it occurs within three, or, more rarely, four weeks from the 
invasion of scarlet fever, to be followed by a more or less marked at- 
tack of some form of dropsy. It is true, we are well aware, that drop- 
sical effusions sometimes take place in subjects who have been guarded 
in the most careful possible manner, and in whom there has been no evi- 
dent exposure to cold; but it is also true, that a much larger number of 
those who have been thus guarded, escape, than of those who are not 
thus taken care of. We have, therefore, no doubt whatever, that it is 
most wise and prudent to confine the patient to well-warmed rooms, or at 
least to the house, for twenty-one or twenty-eight days from the outset 
of the disease. The fact that the attack has been a slight one only 
makes it the more necessary to carry out this regulation, as it has been 
found by experience that dropsy occurs more frequently after mild than 
after severe attacks. M. Legendre (Eecherches Anat.- Pathol.^ p. 311) is 
of opinion that the patient ought not to be allowed to leave the house 
until the skin, completelj^- dej^rived of the old epidermis, shall have re- 
gained its suppleness, its smooth and polished appearance, and all its 
functions. When, therefore, after a mild case, the desquamation is 
completely terminated in three weeks, the patient, he thinks, may be 
allowed to go out. But, on the contrary, this period would be too short 
by one-half, if the eruption had been very intense, as the desquamation 
is, in such cases, scarcely finished on the hands and feet at that time. 
Our own opinion, as already stated, is, that in the cool seasons of 
the year, the patient ought to be restricted to the house during full 
four weeks. 

Treatment or Mild Cases.— Mild cases of this disease, those in 
which the eruption is moderate in degree, the temperature but little 
above the normal point, even though the pulse be very frequent, in 
which neither delirium, stupor, nor unnatural jactitation betray threat- 
ening conditions of the nerve-centres, need but the simplest treatment. 
The child must be confined to a comfortable, well-ventilated room, and 
cooling drinks, as cold water, lemonade, or orangeade, should be 
allowed, and indeed they ought to be recommended, and the nurse 



TREATMENT OF MILD CASES. 739 

should be made to understand that she is not to wait until a young 
child calls out for drink, but that she is to offer it frequently. Young 
children, or at least some, seem not to know when they are thirsty or 
hot or cold ; they have not yet learned to express their sensations in 
words, and a wise nurse or physician will act for them. 

In all cases in which there is heat of skin and frequent pulse, and 
these conditions attend all but a very small fraction of the whole num- 
ber, the patient ought to be kept in bed whilst the fever lasts, and for 
two days afterwards. This point in the treatment of all fevers is a 
most important one, and is too often neglected. Cases so treated are 
apt to be shorter in their duration, milder in their symptoms, and less 
likely to be followed by any of the troublesome sequelas so prone to 
occur, as inflammations of the cervical glands, of the ear, or of the 
kidneys. 

In many mild cases no drug whatever is needed. If the bowels are 
positively costive, that is to say, if they are not moved every second 
or third day spontaneously, a simple enema, a dose of syrup of rhubarb, 
a baked apple, or stewed prunes, will suffice. If the temperature is high, 
the pulse active, and the patient restless and suffering, sweet spirit of 
nitre, solution of the acetate of ammonia, or two or three grains of the 
citrate of potash, with from a half to one drop of deodorized tincture of 
opium, every two or three hours, according to the age, will usually 
lessen the heat and promote quiet. We wish to repeat, however, our 
opinion that in a great many cases of this type, no drugs whatever are 
necessary. The time is fast coming when even the vulgar and illiterate 
will no longer quarrel with the physician because he gives no drugs, 
not even in infinitesimal doses, and the time has come when the wise 
and educated trust the intelligent physician, so that he need no longer 
give placebos merely for the sake of seeming to earn his fee. 

The diet in these cases should be, for the first five or six days, in 
great measure liquid. Milk, with or without some farinaceous sub- 
stance, to suit the tastes or habits of the patient, or with bread and 
butter, beef or chicken soup, with rice or bread, are sufficient. After 
five or six days, when no severer symptoms have made their appear- 
ance, and the disease is on the decline, light meats, eggs, stewed fruits, 
or potatoes, may be added. 

Baths, tepid or warm, or spongings with tepid or warm water, cloths 
wetted with cold or tepid water, applied to the forehead, may be used, 
according to the judgment of the physician. They are not necessary 
agents, but in certain cases, when the heat of skin tends upwards, when 
the patient is very restless from nervous irritation, and particularly if 
the child is in the habit of being bathed, they may be used with much 
advantage and comfort. 

The throat, in mild cases, rarely needs any special treatment. If, 
however, the patient complains of pain, if there be some uneasiness in 
swallowing, or if decided patches of exudation make their appearance 
on the tonsils or pharynx, it will be well to let the child gargle, if it 
be old enough, with solution of chlorate of potash or alum or with flax- 



740 SCARLET FEVER. 

seed tea. An excellent gargle is one niade of a wineglassful of table 
claret, two wineglassfuls of water, and forty grains of chlorate of pot- 
ash. If the patient is too young to gargle, some chlorate of potash or 
alum can be mixed with powdered sugar, and a small pinch placed 
upon the tongue every two or three hours. One part of the chlorate 
or alum may be rubbed up with five or six parts of the sugar. There 
is no necessity for the application of strong agents of any kind to the 
throat. Even though patches of exudation of considerable size appear 
upon the fauces, they will disappear spontaneously^ in all cases of the 
kind we are discussing. We object to the forcible application of medici- 
nal solutions to the throat in young children, unless they are absolutely 
necessary to clear the passages of obstructing viscid and offensive se- 
cretions. In children of a certain t^^pe — those of sensitive nerves and 
strong wills, in whom fear of pain on the one hand and will to resist on 
the other form a combination which prompts the child to resist such an 
operation to the last — even though we might hope some benefit from 
the application, the irritation and exhaustion caused by the struggle, 
and the agitation kept up by its expected renewal, will do more harm, 
we think, than the treatment can compensate for. 

Inunction, as one of the means of treatment in scarlet fever, is now 
so well known that we suppose nearly all physicians use it. For our 
part, we order the ointment for external use just as regularly nowadays 
as we do cold drinks and proper food. 

It was first proposed and strongly urged, we believe, upon the pro- 
fession, by Dr. Schneeman, a German physician. Dr. Schneeman makes 
use of bacon fat. He takes a piece about as large as the hand, still 
covered with its rind, in order to obtain a firm grasp upon it. On the 
soft side of the piece slits are made in various directions in order to 
allow the oozing out of the fat. The patient is to be rubbed with this 
as soon as we are aware of the nature of the case, from head to foot, 
excepting the face and scalp, every morning and evening. The rubbing 
is to be so performed that the skin may be regularly but not too quickly 
saturated with the fat. During the process only the part being rubbed 
is to be uncovered, or the whole can be done under the bed-clothes. 
{Banking's Abst, No. 12, p. 26.) 

For our own part, we used the bacon fat but twice, soon finding how dis- 
agreeable an application it was, and not believing that the salt it con- 
tained could do any good whatever. We now always employ an oint- 
ment made by rubbing together a drachm of pure glj' cerin with an ounce 
of cold cream (ungt. aq. rosse). We have seen children smeared from 
head to foot with lard, and, what is worse, with goose-grease, with their 
clothing saturated, their pillows and sheets a mass of discolored grease, 
most offensive to the eyes and nostrils. This is quite unnecessary. Our 
own method is to explain to the mother or nurse that she must take a 
little of the ointment above recommended in the palm of the hand, and 
with this rub gently the various parts of the surface, first one limb, 
then another, and then the body. The ointment should be rubbed in 
with gentle pressure, and it is well, we think, to knead and squeeze 



TKEATMENT OF GRAVE CASES. 741 

lightly the various portions of the body being anointed, as is done in 
the use of the ??m^«5a^e of the French, or by the "rubber" of the English. 
These manipulations assist, we think, the capillary circulation, which is 
often a good deal impeded. After applying a moderate amount of the 
ointment, while the skin is well softened and oiled, any excess of the 
material should be wiped off with a soft towel or handkerchief. In this 
way the anointing is thoroughly accomplished, and yet the clothing 
and bed linen are not so soaked and saturated with the oleaginous sub- 
stance as to be disagreeable to the patient, nurse, or mother. 

There can be no doubt, at the present time, that the employment of 
inunction in scarlet fever has proved a most useful addition to our for- 
mer means of treatment. In our hands it has had the effect of allaying, 
in all cases, the violent irritation caused by the intense heat and inflam- 
mation of the skin. In nearly all cases, it sensibly diminishes the fre- 
quency of the pulse, and in many this effect is very strongly marked. 
It removes, of course, the drj^ness and harshness of the skin, keeping 
it, instead, soft and moist. It lessens or even removes the burning, 
irritation, and itching caused by the eruption. By these effects, to wit, 
lowering of the pulse, and alleviation of the external heat, dryness, 
itching, and irritation, it cannot but, and evidently does modify and 
diminish, most happily, the injurious effects of the disease upon the 
constitution at large. So great is the comfort it gives to the patient 
that we have several times had young children, still untaught to speak, 
to make signs and motions, at shorter or longer intervals, showing their 
desire to have the application renewed. The frequency of the appli- 
cation must depend upon the case. When the eruption is intense, the 
skin very hot, and the febrile symptoms marked, they should be made 
every two or four hours, or even often er. In milder cases they need 
to be repeated only three or four times in the twenty-four hours. 

Treatment of G-rave Cases. — The most dangerous cases of this dis- 
ease are those of the type described at page 707, in which the attack is 
sudden, and in which disorders of the nervous system in the form of 
convulsions, tremors or rigiditj^, retraction of the head, delirium, 
stupor, or coma appear within a few hours of the onset. When this 
type of the disease attacks very young children, they, so far as we have 
seen, nearly always die in 16, 24, or 48 hours. Older children have 
more chance of escape, but, even in them, the danger is extreme. 

We have seen everything tried in these cases, from depletion by 
bleeding and leeching, many years since, to expectancy, and must con- 
fess that we have little faith in the power of human agency to contend 
against this particular array of symptoms. Depletion is no longer, we 
believe, thought of by any, and there is often no time for the action of 
drugs. 

It is in such cases that the use of water at different temperatures, 
and applied in the form of baths, affusions, packings, ablutions, and ice, 
has been recommended, and has seemed in some cases to do good. We 
shall give a rapid sketch of the opinions of those who have used these 
means, and then state our own views. 



742 SCARLET FEVER. 

Dr. J. Currie, of Edinburgh, was the one who first and most promi- 
nently brought before the profession the use of cold water in this dis- 
ease. It must be observed, however, that Dr. Currie limits its use to 
cases to which he applies the term anginose, many of which, we doubt 
not from his description, ought to be classed as mild cases. He men- 
tions another class of cases which he thinks ought rather to be called 
"purpurata," characterized by " extreme feebleness and rapidity of the 

pulse, and great fetor of the breath The heat does not rise much 

above the standard of health. Great debility, oppression, headache, 
pain in the back, vomiting, and sometimes purging, accompany its 
rapid progress; the patient sinks into the low delirium, and expires on 

the second, third, or fourth day The cold affusion is scarcely 

applicable to it, and tlie tepid affusion makes little impression upon it. 
In my experience, indeed, all remedies have been equally unsuccessful. 
It outstrips in rapidit}", and it equals in fatality, the purple confluent 
small-pox, to which it may be compared." (Currie's Med. Reports, 
Philada. ed., p. 277.) It is clear, therefore, that Dr. Currie, when he 
speaks of nearly invariable success in upwards of one hundred and fifty 
cases (p. 286), had to do, not with the malignant, or, at least, not with 
the most malignant forms, for which we are seeking a remedy, but with 
cases of a mild form, or at most with those of the severe anginose type. 
Indeed, at page 294, we find the following remarks: "It has come to 
my knowledge, that in two cases of scarlatina, of the most malignant 
nature, the patients have been taken out of bed, under the low delir- 
ium, with the skin cool and moist, and the pulse scarcely perceptible. 
In this state, supported by the attendants, several gallons of perfectly 
cold water were madly poured over them, on the supposed authority 
of this work ! I need scarcely add that the effects were almost imme- 
diately fatal." We have been induced to enter thus much into detail, 
in regard to the use of cold affusions, because of the intrinsic impor- 
tance of the subject, and because of the remarks upon it in the work 
of MM. Hilliet and Barthez, who bring forward Currie's success as a 
strong argument in favor of their employment of them in that form of 
the disease in which cerebral symptoms predominate. Currie does not 
recommend them, however, except in cases in which the reaction is full 
and strong, as indicated by very great heat of skin, scarlet eruption, 
and rapid, but not feeble pulse. In the famous cases of his own two 
children, it is evident that the attacks were not malignant, for the skin 
was very hot (108° and 109° F.), and no mention is made either of 
stupor or delirium, much less of convulsive phenomena. Dr. George 
Gregory, of London, whose opinions upon all matters connected with 
the eruptive fevers are of course worthy of great weight, says {Led. on 
the Eruptive Fevers, edited by Dr. Bulkley, New York, p. 190), in rela- 
tion to the use of cold affusions: " Sanctioned by my uncle, the late 
Dr. Gregory, of Edinburgh, this plan has been amply tried in all parts 
of the world, but it has not realized the expectations of its proposer. 

" The truth is that the cold affusion is applicable only to a small 
number of cases. It is adapted for young people with high anginose 



TREATMENT OF GRAVE CASES. 743 

inflammation and a burning hot skin, without plethora, without de- 
pression of nervous energy- but it is inapplicable to the scarlatina of 
adults, accompanied with coma, phrenitis, or marked debilit3\ It is 
wholly unfit for cases of cynanche maligna. It answers its purpose 
very well for the first day or two, but it is often impossible to continue 
its use. Lastly, it seems to increase the disposition to dropsy." 

Dr. Currie's method of using water was by effusion. The child is 
undressed and placed erect or sitting in a tub, while four or five gallons 
of water, at from 60° to 70° F., are poured over the head and body. 
The good effects of the remedy are said to be an immediate reduction 
of the heat, a diminution in the rapidity of the pulse, which, in one of 
Dr. Gregory's children, fell in half an hour after the cold affusion from 
160 to 120, a disposition to sleep and quiet, and, according to Dr. Greg- 
ory, a seeming arrest of the throat-affection. These good effects of the 
affusions are transient, however, as the heat of skin and rapidity of 
the circulation return in the course of one or two hours. For this 
reason it is necessary to repeat them frequently, once in two or three 
hours at least, in order to render the effects permanent. Currie used 
fourteen affusions for one of his own children, and twelve for another, 
in thirty-two hours. These were not, however, all cold. Gregory used 
for his child five " good sousings," to use his own words, in twenty-four 
hours. 

MM. Eilliet and Barthez give, in the following words, the conclusions 
of Henke in regard to the use of cold affusions : 1. Cold affusions are 
not adapted for a general method of treatment. 2. The slight^ or simply 
inflammatory forms, do not all demand so energetic a treatment. 3. 
Their employment must be reserved for cases in which the disease is 
epidemic, and accompanied by intense heat and dryness of the skin, 
with smallness and acceleration of the pulse, and for those in which the 
cerebral symptoms are very violent and characterized by great rest- 
lessness, alternating with drowsiness, commencing from an early period 
of the disease. Scarlet fever under these circumstances is so danger- 
ous, they say, and so often mortal, that recourse ought to be had to all 
curative means, and in children the cold affusions are much more 
strongly indicated than bleeding (op. cit., vol. ii, p. 653). 

Dr. Hiram Corson, of Montgomery County, in this State, has, so far as 
we know, used cold externally more boldly than any one in this country. 
He began this treatment in 1814, and, in a report made by him to the 
Pennsylvania State Medical Society "On the External Application of 
Ice to the Throat as a Remedy in Scarlet Fever and Diphtheria" (see 
Transact, of the Med. Soc. of the State of Pennsylvania, for the year 1864), 
declares his unabated faith in the excellence and safety of the treat- 
ment. He advises, in cases attended with convulsions, the pouring of 
cold water from a height of a few feet on the head for several minutes 
at a time, — this to be repeated every fifteen or twenty minutes until 
relief is obtained. At page 467, he says: '-Hundreds of times have I 
had patients brought to the side of the bed and cold water poured 
freely over the head, until the stupid, almost comatose child, was 



744 SCARLET FEVER. 

yelling, and kicking, and striking to get rid of the falling water; and 
this I have repeated whenever the symptoms called for its repetition." 
He prefers in these cases the cold affusion to ice. He also applied pieces 
of ice wrapped in cloths, to the neck, when the anginose symptoms were 
severe, and, when the temperature was very high, washed the whole 
body with iced water, until the heat was reduced. 

Dr. Corson, in this article, speaks with the greatest possible confi- 
dence of his treatment, and when others evince some dnbitation as to 
the invariable success of the cold treatment, avers that they had used 
it imperfectly or with timidity. It is really unfortunate that his paper 
deals altogether in general assertions. At page 458, he says: "And 
now, after twenty years of experience in the use of it, and after treat- 
ing scores and scores of cases, I am most happy to say that I have 
never seen the least injury produced by it, but, on the contrary, regard 
it as the means, above all others, of comfort and safety to the patient." 
He does not refer to a single fatal case during the twenty years he has 
been using this system. At page 453, however, he speaks of having 
"during the whole winter, in about one hundred cases, continued the 
treatment in degrees apportioned to their mildness or severity, and 
without the loss of a single patient thus treated." 

Nevertheless his experience is valuable, for it shows that, in some 
cases, at least, the use of means which reduce rapidly the heightened 
temperature of the body in scarlet fever, acts as favorably as it has 
been found to do in the hyperpyrexia of sunstroke, rheumatic fever, 
and in continued fevers. 

Hillier (Dis. of Children, p. 326) states that he has employed cold 
affusions with good effects in a few malignant cases. He used water 
from 70° to 75° F., wrapping the child immediately after the affusion 
in dr}^ blankets. He adds that "in cases of collapse with cold extremi- 
ties, it would not be prudent to resort to the operation." 

Trousseau {Clin. Med., Syd. Soc. ed., vol. ii), recommends cool or cold 
affusions when dangerous ataxic nervous symptoms make their appear- 
ance. At page 198, he says: " I declare to you that I have never re- 
sorted to the employment of cold affusions without obtaining beneficial 
results. I am far from pretending that all my patients recovered: like 
my colleagues, I have lost the greater number, but even those who died 
experienced a temporary relief from suffering, and the affusion, so far 
from proving injurious to them, always moderated the symptoms, and 
also seemed always to retard the fatal termination." At page 206, he 
states that he does not use them indiscriminately in all cases, but 
only " to subdue serious nervous complications — formidable ataxic 
symptoms." 

Dr. Gee (Reynolds's Syst. of Med., vol. i) speaks of the cold affusion as 
being sometimes useful in the malignant form of the disease, attended 
with delirium, diarrhoea, vomiting, full pulse, and great heat of skin. He 
adds, however (p. 355), that in the "primary adynamic form, all treat- 
ment will be baffled. The cold affusion is the only means which has 
seemed to me to be of even momentary benefit." 



TREATMENT OF GRAVE CASES. 745 

We shall now refer to our own experience in the employment of ex- 
ternal cold. We never use it to its full extent except in really dan- 
gerous cases. So long as the case is mild or moderate, or even severe; 
if there be no cerebral, and especially no locomotor disturbances, we 
deem it unnecessary, and rest content with more simple means; or we 
use simply ablutions with tepid or cool water, with cold applications to 
the head, so long as they are agreeable, and until the temperature is 
reduced. But, when the temperature rises very high (105°), or, as 
Currie states in one case 112°, and Dr. Woodman (Wunderlich on Med- 
ical Thermometry, Syd. Soc. ed., p. 204, footnote), 115° F., with nervous 
symptoms, the danger is extreme, and we have used, and shall use here- 
after, means to reduce the heat. In one case we made repeated affu- 
sions upon the head with water at 70°, pouring at one time seven buck- 
etfuls upon the part. This was a case attended with coma, strabismus, 
and spasmodic retraction of the head. In addition to the affusions, 
cloths dipped into iced water, were kept applied the greater part of the 
time. These means, especially the affusions, were evidently advanta- 
geous, and the child recovered. 

We have made use of lotions with cool water (70° to 72°) in three 
grave cases. In two they were evidently useful; in one they did no 
good, and were perhaps injurious, as we believe now that the case 
might have been better treated with prolonged warm baths at a tem- 
perature of 92° to 95°, cold to the head, and internal stimulation. The 
latter case was one in which the patient had two convulsions on the 
first day, and one on the second. The pulse rose at once to between 
160 and 170 ; the head and trunk were very hot, whilst the extremities 
werecoolish; the child was either excessively dull or comatose. Cloths 
w^et with iced water were kejDt constantly upon the head and the body, 
and occasionally the limbs were sponged with cold water. The internal 
remedies consisted of carbonate of ammonia and milk-punch. The 
patient improved decidedly on the third day, so that the pulse came 
down to 152, the intelligence returned, though the child was still very 
drowsy and heavy, and the case looked quite promising. On the fourth 
and fifth days, the throat-affection came on ; the neck and throat 
swelled enormously, the cervical lymphatic glands became very large, 
the nasal passages discharged streams of offensive grumous pus, the 
ears ran coj^iously, the fauces became pseudo-membranous, the deglu- 
tition grew worse and worse, nntil at last it was impossible, and the 
child died on the middle of the sixth day, a mass of the most disgusting 
and offensive disease. One of the grave cases in which the cool appli- 
cations proved useful, occurred in a hearty, vigorous girl, twelve years 
of age. On the third day of the attack, the symptoms were as follows : 
the pulse was between 160 and 170, small and quick; skin intensely 
hot ; eruption very copious and of a dark red color tending to violet ; 
capillary circulation slow and languid ; tongue black, and covered with 
a hard, dry crust; teeth and lips dry, and covered with dark incrusta- 
tions. There was very great agitation and restlessness, with constant 
moaning and complaining, and total insomnia. Under these circum- 



746 SCARLET FEVER. 

stances, we directed the nurse to sponge the head and extremities of the 
patient with water of the temperature of the room (68° to 70°). As 
the water became heated by contact with the skin, small pieces of ice 
were put into the basin so as to keep the temperature at the point men- 
tioned. At the end of four hours, the washing having been continued 
all the time, we found the patient decidedly more comfortable. The 
pulse had fallen to 140, and increased in volume ; the heat of skin was 
much reduced; the color of the eruption had improved, having become 
much more scarlet in tint; the capillary circulation was more active ; 
the agitation and restlessness had very much moderated, and the child 
had slept somewhat at short intervals. This treatment, in conjunction 
with the internal administration of the solution of chlorinated soda, and 
small doses of spirit of turpentine, was continued for several days, the 
sponging being used whenever the heat and restlessness were great, and 
the pulse very rapid. The child convalesced about the end of the third 
week, but was unfortunately seized with ursemic symptoms on the 
twenty-fifth day, and died in twenty-three hours, after the most fright- 
ful convulsions we ever saw. 

Since the publication of the last edition of this work we have seen 
but little grave scarlet fever, and our experience as to the exact value 
of cold has not been much increased. It was used by our advice in the 
following case, of the most violent type, to which we were called in 
consultation. 

Case. — The patient was a girl, two years old, who, seized in the morning of one 
day with vomiting, fever, and restlessness, had, during the following night, hot fever, 
violent jactitation, and moaning. She refused all food. Next day, at 9 a.m., when 
we saw her, she was imminently ill. She knew no one, paid no attention to father or 
mother, tossed incessantly about the bed or in their arms, so that it was almost im- 
possible to hold her ; and at times had rigid contractions of the muscles, like those 
in tetanus. The features were drawn and rigid ; the pulse running upwards of 180, 
very feeble and small; the skin very hot, but there was no eruption. The latter fact 
might throw some doubt on the diagnosis ; but the character of the symptoms, the 
rapid fatality, and the fact that a few days afterwards two children were seized with 
distinct scarlet fever in the house opposite, leaves no doubt in our own mind. The 
prognosis was as bad as it could be, and so we announced, but added that external 
cold ought to be tried. The body temperature was very high, and we directed basins 
of water with ice in it, as used by Dr. Corson, to be prepared. Towels wrung out 
of this water were kept on the head, and the body and limbs sponged with the same 
until the heat fell, when the washings were suspended temporarily, to be renewed 
when the heat rose again. The treatment was carried out very correctly, as there 
was a medical man present all the time, but it was of no use whatever. The child 
died at 12 m. of that day, in a little over twenty-four hours from the onset. 

This case was not a fair test of the value of the treatment. The cold 
was applied too late to show clearly what may be its power. But we 
confess that its total failure, though used within twenty-four hours of 
the inception of the disease, is a melancholy proof of the extreme dan- 
ger of such cases. 

A second case, which occurred about the same time, also shows the 
violence of this form of the disease. 



TREATMENT OF GRAVE CASES. 747 

Case. — A very healthy girl, within a few days of two years old, whose sister and two 
of whose cousins had been ill with scarlatina in the same house for some ten days, was 
seized at six in the morning with vomiting. She then slept for a time and vomited 
again. At 9 a.m. she had a convulsion, which lasted, with short lulls, during which 
she was comatose, until 6 p.m., when one of us saw her in consultation. She was 
then very hot, covered with a copious, dark, dingy eruption, and insensible. Despair- 
ing of any other treatment, we advised cold externally, and arranged for its use by a 
physician, with the thermometer as a guide. Before the treatment could be com- 
menced, the child became again convulsed and died. 

After thus stating the conditions under which we think external cold 
may be properly used, we must protest against its indiscriminate use in 
all cases of dangerous scarlet fever. If the reader will glance back at 
page 742, he will see what Currie thought of the rash use of his cold 
affusions, and what Dr. Gregory also states of the effects of cold. 

When the body, instead of being hot, is cool — when a dingy and 
stagnant capillary circulation shows a feeble and struggling heart, it 
would be most dangerous to use cold. Here the warm or tepid bath or 
affusion should be used, or warm mustard foot-baths may be resorted 
to every two or three hours. If, even whilst the body and limbs are 
cool, the head is hot, it would be proper to apply cold by cloths or affu- 
sion to that part, whilst the body is immersed in warm water or wraj)ped 
in proper coverings. 

The true guide as to the propriety or impropriety of using cold is, 
none can doubt now, to be found in the thermometer. The method fol- 
lowed by Drs. AYilson Fox and H. Weber in the cases of hyperpyrexia 
occurring in the course of rheumatic fever is the one which we propose 
to use ourselves and to recommend to others. It is the only scientific 
one, and therefore the one which can be accurately described and fol- 
lowed. If errors occur, they can be definitely' stated and afterwards 
avoided. If successful, the exact means which led to success can be 
ascertained and communicated in precise language. Dr. Fox published 
his cases first in the London Lancet^ and then presented them in a sep- 
arate form as an essay, "On the Treatment of Hyperpyrexia, as Illus- 
trated in Acute Articular Eheumatism, by Means of the External Ap- 
plication of Cold;" Macmillan & Co., London, 1871. Dr. H. Weber's 
case is to be found in the Transactions of the Clinical Society of Lo7idon, 
vol. V, p. 136, under the title of "A Case of Hyperpyrexia (Heat- 
stroke) in Eheumatic Fever Successfully Treated by Cool Baths and 
Affusions." 

The first point to be determined is the degree of temperature which 
becomes dangerous to life, and to prevent or reduce which we may and 
ought to resort to the application of cold externally. Of course there 
is but one certain guide to the temperature of the human body, — the 
thermometer. A practised hand may be relied on when no thermom- 
eter is to be had; but no hand, however experienced, can give the cer- 
taint}^ of the thermometer. Inasmuch, too, as the state of hyperpyrexia 
is always attended by concomitant phenomena of a peculiar kind, these, 
to the experienced physician, will assist in guiding him in his treatment. 



748 SCARLET FEVER. 

These phenomena constitute the group called ataxic or ad^^namic ner- 
vous symptoms. The patient is usually delirious and restless or coma- 
tose, and not unfrequently has local or general convulsive movements; 
the pulse is frequent and feeble, and sometimes so small as to be felt 
with difficulty, and the capillary circulation is sluggish and congested; 
the respiration is usually hurried and embarrassed, so that the patient 
is readil}^ judged to be in extreme danger. 

According to Dr. Fox, a temperature in rheumatic fever which rises 
suddenly from 103° or 104° to 107°, 108°, or 109°, has usually proved 
fatal within a very short time after the latter temperature (109°) has 
been reached. He, however, saved one patient, by external cold, in 
whom it reached 110° in the rectum. Dr. H. Weber thinks that until 
the cold treatment was used, a temperature of 108° had been nearly 
always fatal. Dr. Fox asks the question. After what degree of tem- 
perature attained by the human body in febrile states is recovery nat- 
urally possible without medical interference? He states that the 
highest recorded temperature he knows of after which recovery has 
taken place (with the exception of relapsing fever), was in a case of tu- 
bercular pneumonia, in which it rose suddenly from 105° to 108°, and 
then suddenly fell to 101°. He refers, of course, to cases not treated 
by cold, since, as stated above, he himself saved a case in which the 
temperature had reached 110° in the rectum. 

It must not be forgotten that the axillary temperature is less than 
that of the mouth, under the tongue, and that this is less than that of 
the vagina or unloaded rectum. Wunderlich gives the averages in the 
adult as follows: For the axilla, 98.6° F. ; for the mouth, 98.78° to 
98.96° ; and that of the vagina or unloaded rectum, 99.14° to 99.5° F. 
In children the temperature is more variable, but does not differ very 
greatly from that of the adult. M. Eoger gives 98.97° as the average 
axillary temperature between 4 months and 6 years, and 99.15° between 
6 and 14 years. Dr. Finlayson, in 21 children under 6 years, found the 
morning temperature in the rectum to be 99.41° F. 

Such being the normal temperatures, we will now give those which 
have been observed in scarlet fever. Wunderlich (Med. Thermometry, 
Syd. Soc. ed., p. 348) says that the height reached by the temperature 
in scarlet fever is almost always above 104° F., very commonly over 
104.9°, while in cases which terminate favorably it seldom exceeds 
105.8° F. The translator of Wunderlich (Dr. Woodman, footnote, p. 
221) gives the noon temperature of tj^pical non-malignant scarlatina in a 
good many cases as 105°, 104°, 103°, and 102°, on the first, second, third, 
and fourth days. In a note at page 201, he states that he has put on 
record (Med. Mirror for February, 1865) some fatal cases of scarlet fever 
in which the temperature reached 115°. " The observations were made 
with one of Negretti and Tambra's thermometers, divided into fifths, 
which had been recently compared with a standard." 

From these facts we may assume that a temperature of 105° F. in 
scarlet fever is not necessarily xqvj dangerous to life, but that from the 



TREATMENT OF GRAVE CASES. 749 

moment it tends to rise above this point, the patient enters into a very 
dangerous period. 

If, with a temperature of 105°, there appear any of the nervous phe- 
nomena so often alluded to, delirium, drowsiness, coma, vomiting or 
purging, and especially any locomotor disturbances, the time has come 
for the use of external cold; and should the temperature continue to rise 
after it has reached 105°, the cold treatment ought to be resorted to, 
even though these nervous phenomena have not shown themselves, 
since they will be almost certain to appear should the temperature go 
on rising. 

And next as to the best mode of applying cold. It does not matter 
much how this is done, if only it be so managed as to reduce with cer- 
tainty the heat of the body towards the normal point. Dr. Fox used 
baths at different temperatures, and in one case applied ice to the chest 
and along the spine in an ice-bag, whilst he reduced the temperature 
of the bath rapidly from 96° to 66°. At other moments in the same case 
he used the ice-bag applied to the spine for several hours at a time, and 
on still other occasions employed the cold pack, wrapping his patient 
in a sheet wrung out of ordinary cold water (probably 60°). Dr. H. 
Weber placed his patient (a boy of 16) in a bath at 71° F., keeping him 
there the first time thirty minutes, when the temperature under the 
tono-ue had fallen from 108.2° to 101.8°. Some hours afterwards, when 
the temperature had risen to 105.8°, the patient was again put into 
a bath at 72°, and water poured over the back of the head and neck. 
In twenty-five minutes the temperature fell to 101°. 

Dr. Fox saj^s, at page 84: "I believe, however, that the bath may 
be altogether dispensed with, and that for the future it will be sufiici- 
ent to place a Mackintosh sheet under the patients, so arranged that 
the water may escape into a receptacle, and to pour cold water over 
them from time to time." 

Dr. Corson uses affusions of cold water over the head of the child, 
w^hich is held over a tub, as the most powerful means in cases of coma 
or convulsions, and, when the temperature is \qyj high, washes the 
whole body with iced water, or even rubs it with ice. 

The most convenient mode, it appears to us, in children, will be 
either the one proposed by Dr. Fox, the Mackintosh sheet on the bed, 
and affusions of cold water; or a bath-tub or common large wash-tab, 
containing water at a temperature proportioned to the heat of the 
body, 80° to 70°, with affusions of cold water upon the head, or the 
application of towels wrung out of cold or iced water to the head. So 
soon as the thermometer, held in the rectum or under the tongue, shows 
that the temperature has fallen to 101° or 102°, it will be best to remove 
the patient to bed between two blankets. Not unfrequently, as the tem- 
perature falls, the patient becomes partially conscious, grows paler, and 
shivers, and these are signs which show that it is time to cease, at least 
temporarily, the use of the cold. 

The physician, when he first uses this mode of treatment, should 
know that the temperature is apt to continue to fall, even after the use 



750 SCARLET FEVER. 

of the cold has been suspended. Thus, in one of Dr. Fox's patients it 
fell from 103° to 99.4° after the removal from the bath. The danger 
to be apprehended from these continued falls in the temperature is not 
so great as might be supposed. Thus, Dr. Fox says that it may be 
doubted whether, in future cases, any external warmth may be necessary 
to prevent too great a fall of temperature. " Even severe collapse pro- 
duced by cold has been shown by F. Weber's, Bartel's, and Ziemssen's 
observations on the pneumonia of children to be less dangerous than it 
at first appears." And Dr. H. Weber sa3^s, " Although the duration of 
the bath will be influenced in some degree by the temperature of the 
water, we must be entirely guided by the conditioQ of the patient while 
in the bath; the heat of the blood ought to be reduced, if possible, to 
almost its normal degree, and the nerve-centres ought to be reduced to 
a more healthy condition." 

After the heat has been once reduced by the cold to near its normal 
state, the patient must be carefully watched by means of the thermom- 
eter, and if the heat rises again, the cold should be reapplied. This 
may have to be done several times a day at first, and less frequently 
afterwards, if the treatment prove successful. It is not always neces- 
sary to resort to the bath in every rise of the heat. Cold to the head, 
aff*usions upon the head alone, the application of an ice-bag to the spine, 
or the use of the cold bath, may sufiice to kee]) the temperature within 
the safe limits. 

While the cold is being used to reduce the temperature, we may em- 
ploy certain internal remedies with advantage. If the patient is not 
very much exhausted, we may make use of the antiseptic salts of Polli, 
to which reference will presently be made. But if the exhaustion be 
very great, if the circulation is rapid, feeble, and uncertain, with a 
dusky and congested skin, we should use brandy with milk, beef or 
chicken tea, and wine-whey. Dr. Fox used in the two cases which re- 
covered (adults) very large quantities of brandy, from twelve to eigh- 
teen, and even thirty-three, ounces in twenty-four hours. He gave also 
large amounts of beef tea, two to three pints, and as much milk as three 
and four pints. In such cases quinia and carbonate of ammonia would 
also be proper means until the vitality is restored. 

In the last edition of this work it was stated that we had used the 
hyposulphite of soda or magnesia in 11 cases, of which 2 were malignant 
in type. 3 grave, and 6 moderate. All these recovered. It was then 
said that so small an experience was of little weight in determining 
their value. Since that time we have used the same salts in most of 
the cases that we have seen. Only 4 of these could be called grave. 
They were not of the convulsive form, but exhibited high fever, severe 
anginose symptoms, tedious duration, and copious desquamation. They 
were severe, but not malignant cases, and they all did well. In two 
cases of the malignant form, with profound adynamic nervous symp- 
toms from the very onset, they were also freely used, but without effect. 
On the whole, we think these salts deserve a further trial. The soda or 
magnesia salt ought to be selected according to the state of the bowels. 



TREATMENT OF GRAVE CASES. 



751 



When these are constipated, the magnesia is to be used. In the con- 
trary case, or when the bowels are in a relaxed state, we use the soda 
salt. The dose of either is live or ten grains, every two hours, accord- 
ing to the age. They are best given in solution in water, with a little 
ginger syrup. 

There are a class of cases which, though they do not exhibit the ex- 
treme severity of those we have just considered^ well deserve the name 
of grave. The temperature is high, the pulse rapid, the nervous 
system shows disturbance by extreme agitation or by drowsiness; there 
may be muscular starting, or tremors, or a single slight convulsion; 
the eruption is very abundant, and vivid or dark in tint, and the angi- 
nose symptoms are marked and severe. Such cases are dangerous; 
seldom last less than two or three weeks, and require all the care of the 
practitioner and nurse. 

In this second grade of the grave form the temperature ought to be 
reduced, using the thermometer as a guide, at the beginning by the 
careful use of the cool or tepid bath, or by cool or tepid ablutions, and 
by the use of cold water or ice to the head. Internally the hyposul- 
phite salts or an alkaline febrifuge ought to be administered for the 
first few days. 

The patient often, indeed generally, in this class of cases, sinks after 
a few days, into a low ataxic condition. Here the best remedies, we 
think, are chlorate of potash with muriated tincture of iron, quinia 
with muriated tincture of iron, or muriated tincture of iron with solu- 
tion of acetate of ammonia and dilute acetic acid. Hillier thinks that 
in such cases the best medicine is carbonate of ammonia, and Trousseau 
also advises it strongly. These medicines may be given in the follow- 
ing modes : 



B. — Potass. Chlorat., ^j. 

Tr. Ferri Chlorid., fgj. 

Syrup. Zinziberis, ... ..... fjvij. 

Aquse, f^ij.— M. 

Dose, a teaspoonful every two hours at five years of age, and under that age, half 
a teaspoonful. 



R. — Quinise Sulphat., 
Tr. Ferri Chlorid. 
Syrup. Zinzib,, . 
Syrup. Simp., . 
Aquae, 



. gr. xij. 
. f^ij.-M. 



Dose, a teaspoonful every two hours at five years, and under that age, half the 
quantity. 

R.— Tr. Ferri Chlorid., . 
Acid. Acet, Dil., 
Liq, Ammon. Acetat., 
Syrup. Simp., . 
Aquse, 

Dose, a teaspoonful every two hours at five year 
the quantity. 



. f3J- 



f^iss.— M. 



s of age, and under that age, half 



752 SCARLET FEVER. 

The dose of carbonate of ammonia is from two to three grains every 
two hours at five years, given in a mixture of syrup and gum, or in milk 
and water. 

In all severe cases attention to the diet is highly important. At 
first only milk and broths should be allowed. After a few days bread 
or some other farinaceous substance may be added. Until the fever 
has disappeared in great measure, no other diet ought to be permitted. 
The cases are very uncertain in their course. 

Under certain conditions alcohol must be used as has already been 
said. When the tongue is dry, the skin harsh, the pulse rapid and 
feeble, the cardiac impulse weak, the muscular force prostrated, we use 
brandy or whisky, or wine in the form of wine-whey, or mixed with 
water. The choice between these agents must depend on the degree of 
vital, and especially of circulatory, prostration present, and the fancy 
of the patient. We use brandy generally, giving it in milk or water. 
From ten to twenty drops at the age of one or two years ; from twenty 
to forty drops between two and five years of age; and after these ages 
from half a teaspoonful to a teaspoonful every two or four hours, or 
three or four times a day, according to the effects produced upon the 
pulse and nervous symptoms, are the doses we have found best. When 
wine-whey is preferred, one or two teaspoonfuls every hour or two 
hours, at two years of age, and a tablespoonful at the age of four or 
five and upwards, maj^ be given. 

Treatment of the Angina. — The angina is seldom troublesome before 
the third day. It never becomes, we think, a source of danger in itself, 
in the cases destined to end fatally on the first, second, or third day. 
But, when the case begins with grave nervous symptoms, and the 
patient survives these, the throat almost always exhibits, on the third 
or fourth day, the conditions which have already been described, and 
which partake so much of the character of severe diphtheria. The 
general treatment ought to be steadily persevered in — that by the hy- 
posulphites, or by the muriated tincture of iron, with or without chlor- 
ate of potash and quinia, as has been described. The local treatment 
should consist, in the early stage, of cold applications, if the constitu- 
tional state of the patient will allow of it. When the circulation is ac- 
tive, and the temperature of the body high, there need be no fear as to 
the use of cold. When, on the contrary, the heat is not high, it should 
be used with caution, and, if the temperature falls rapidly under its use, 
it must be abandoned, or used only from time to time, and with great 
care. When the temperature continues rather low, warm poultices, in- 
closed in portions of thin, soft flannel, and secured by a light cravat 
round the neck, may be tried. They may prove comforting to the 
patient. 

When the cold is to be used, pieces of ice wrapped in flannel, and 
applied behind the angle of the jaw, or cloths wetted with iced water, 
may be employed. We have used the cold several times, and in 
two cases with marked benefit. In one case, which we shall relate, the 
effects were most striking. 



CASE. 753 

Case. — The patient was a boy between eight and nine j'ears of age, who had had 
slight convulsive movements and delirium on the first day, violent jactitation and 
unconsciousness on the second and third days, with very active pulse, profuse dark 
eruption, and very high temperature. There appeared on the third day threatening 
anginose symptoms. On the fourth these had increased, and, by the night of the 
fifth day, had reached such a height as to make us almost despair of the child's life. 
The violent pharyngeal inflammation was attended with excessive swelling of the 
tonsils, and with oedematous infiltration of the submucous tissue, while externally 
the cervical ghmds were enormously enlarged and as hard as paving-stones, and the 
subcutaneous tissues of the front and lateral regions of the neck were packed and 
hard with acute cedema. The general symptoms were most threatening. Owing to 
the swelling of all the parts composing the neck, the respiration was so much inter- 
fered with as to cause the development of dangerous asphyctic symptoms. The 
pulse, which for the three first days had been running at 168, had fallen on the 
fourth to 140, and on the fifth to 128 ; the skin was hot and dry, and, upon the face, 
had assumed a dark, bluish tint; there was almost constant muttering delirium and 
a degree of tossing and violent jactitation painful to witness. The swallowing was 
so much impeded that it was with great diflSculty that the patient could take the 
thinnest liquids. Up to this time the case had been treated with inunctions, cold 
drinks, and a febrifuge containing spirit of Mindererus and sweet spirit of nitre. In 
the midst of these threatening symptoms, and when we had almost lost hope, the late 
Dr. Charles D. Meigs, who saw the case with us, proposed abandoning all drugs, and 
making use of cold applications externally, and giving stimuli. Accordingly a large 
towel was wrung out of iced water and wrapped around the neck, and weak wine 
and water was given as often as the child could take it. The cloth was dipped afresh 
into the water every few minutes. This treatment was commenced about 1 a.m., 
and carried on steadily all night. At 9 a.m., it was evident that the symptoms had 
somewhat improved, and by the afternoon of that day the patient was greatly better. 
The improvement consisted principally in a moderation of the pharyngeal swelling, 
so that both respiration and deglutition were much easier. The dark color of the face 
had lessened; the pulse had risen in frequency, and was stronger; and the delirium 
and excessive jactitation had almost disappeared. On the day after this the external 
cervical swelling continued very much the same, except that the oedema had notably 
diminished. The pharyngeal swelling had disappeared, the tonsils having regained 
their natural size, but the whole pharynx was covered with a thick mould of white 
exudation. The cold application, which of late had been used more sparingly, was 
now discontinued ; the fauces were touched with a solution of nitrate of silver of 
ten grains to the ounce; broths, milk, wine-whey, and wine and water were given 
for nourishment, and the patient slowly recovered, after having had a large suppu- 
ration just above the inner end of the left clavicle. 

It was at one time very much the custom to make various applica- 
tions to the fauces. Nitrate of silver, pure, or in strong solution, muri- 
atic acid, or capsicum, were deemed necessary and useful. They have 
been very much abandoned, and we think wisely. The agitation and 
terror caused by them in some children, and the violent resistance they 
often make, exhaust the patient, and we therefore avoid them wherever 
we can. Sometimes, however, and especially in young children, viscous 
secretions collect in the fauces in such quantity as to cause serious annoy- 
ance to the child and embarrass the respiration : they ought, therefore, to 
be removed by means of a sponge-mop or camel's-hair brush. This point 
in the treatment is a very important one, especially in young children. 
We believe that we have rescued more than one patient by going three 
or four times a day to make use ourselves of means by which to remove 

48 



754 SCARLET FEVER. 

from the fauces, the viscid, glue-like secretions, the purulent fluids, and 
the masses of pseudo-membranous exudation which collect in and oc- 
clude those passages, and which the child often cannot, b}^ any effort of 
its own, get rid of The best mode of effecting this object is by the use 
of mops, made of sponge or rag, fastened to a stick or whalebone, or 
by the injection from a small sj^riuge or elastic bottle of detergent 
washes or gargles into the throat, the mouth being held open and the 
tongue depressed by the handle of a spoon. One of the best w^ashes 
for this purpose is made of a strong decoction of green tea containing 
alum; or we may employ sage tea and alum ; or honey of roses and 
borax mixed with w^ater; or lime-water; or, what is highly recom- 
mended by Dr. Watson as one of the best, a solution of common salt. 
Muriated tincture of iron, one part to five or six of water, or to one of 
glycerin and five of water, is an excellent local application. In older 
children, gargles of salt and water, alum and water, chlorate of potash, 
in claret and Avater, or plain water, ma}", and ought to be used, when 
possible. When coryza is present, the nasal passages should be cleansed 
by means of camel's-hair brushes, or by the injection of some of the 
mild washes just referred to, and then freel}' anointed with sweet oil or 
some mild ointment, or they may be touched with the wash used for 
the throat. 

Diarrhosa, when present, probably depends on congestion and desqua- 
mation of the intestinal mucous membrane, and should be treated with 
bland demulcent drinks, and absorbent antacids, especially chalk mix- 
ture. 

Mheumatism should be treated by opiates to allay the pain, and the 
sw^oUen joints should be enveloped in bats of cotton. If suppuration 
should occur, either in connection with the rheumatic inflammation of 
the joints, or involving the glands or cellular tissue, and indicating a 
pysemic tendency, large doses of quinia with stimulants should be 
given. The abscesses which may form should be opened so soon as 
fluctuation can be detected. 

For the otorrhoea which sometimes occurs, it is seldom necessary to 
do more during the violence of the attack, than to cleanse the ears 
twice or three times a da}^, by syringing with warm water and castile 
soap, or with a weak solation of alum. After the violence of the attack 
has subsided, this complication should be treated as in idiopathic cases. 

Treatment of Dropsy. — It is our habit; when directing the general 
treatment of a case of scarlet fever, always to explain to the mother or 
nurse, or both, that the most frequent and dangerous sequel to be appre- 
hended in this disease is drops}^, that this is even more apt to follow 
mild than grave cases, and that it usuall}^ occurs in the third or fourth 
week of the disorder, though it does occur, on very rare occasions^ at 
a still later period. AYe also assert our belief that this consequence, or 
complication, or sequela, is apt to be produced by cold, and that sub- 
jects confined to bed through the third and fourth weeks, and those 
rigidly secluded in a warm room for four weeks from the onset of the 
disease, no matter how mild the case, are much less prone to dropsy 



TREATMENT OF DROPSY. 755 

than they who leave their beds or rooms at an early period to take 
the usual chances to which children are exposed. We know well that 
Hebra ridicules the stupidity of English physicians in ascribing so 
many disorders to cold. But, whilst we believe with him that in Eng;- 
land and amongst ourselves the word ^'cold'' is often used both by 
medical men and by the public as a mere scapegoat to bear the weight 
of their ignorance of the real causes of diseases, we also believe, most 
emphatically, that chilling of the human body below its natural stand- 
ard of heat, if it be continued for any length of time, is verj' apt to be 
followed by some disturbance of the health. We are quite sure that 
we have on several occasions, traced a relation of cause and effect be- 
tween exposure to cold in the third or fourth week of scarlet fever 
and a rapidly sequent dropsy. Several such cases are mentioned in the 
section on the symptoms and causes of dropsy, at page 722. We always, 
therefore, urge upon the mother or nurse not to allow the child, in the 
autumn, winter, or spring months, no matter how mild may have been 
the disease, to leave a well-warmed and well-ventilated room for four 
weeks, and, if there be any signs whatever of ailing health at the end 
of the fourth week, to continue the seclusion for one or two more weeks. 
One of the troubles of our private medical career has been the conten- 
tions we have had with people in their hurry to get children, who have 
been sick, out of the nursery. In summer weather, this may be all 
ver}' well, but in the cool and cold months it is not yqtj well, as the 
bills of mortality and the experience of any older physician or experi- 
enced mother, will show. Why a child should lie abed for two or three 
months for a broken bone, without fear for his general health, and 3^et 
be regarded as a suffering martyr, because some tyrannical doctor in- 
sists upon his remaining a few more days or weeks in a comfortable 
chamber, with all the household at his feet, to escape a disease like 
acute Bright's disease, passes our comprehension. 

Before leaving this subject, we wish to say that we have known 
droj)sy to follow scarlet fever in one case, and only in one, in which 
the child had not left the bed. Two children, brother and sister, seven 
and nine years of age respectively, had each a full attack of scarlet 
fever, — the boy rather a severe one. At the end of the third week the 
boy, being perfectly well, was allowed to leave the bed in a warm room. 
In two days he was seized with scanty, albuminous urine and moderate 
dropsy. The girl, who had fallen sick several days after the boy, and 
Avho was small and delicate, was kept in bed continuously, and yet she 
too was attacked with dropsy. Both these cases proved very obstinate, 
and it was several months before they were recovered. 

It is important to recognize the renal disease early. The mother 
should be warned to send for the phj'sician again, if he have resigned 
the charge of the case, should there be any delay or irregularit}' in the 
convalescence, and especially should she observe any unusual scanti- 
ness in the quantity of urine discharged; should this assume a dark 
and especially a brownish or blackish tint; should there be any ful- 






756 



SCARLET FEVER. 



ness of the eyelids, swelling of the cervical glands, or, indeed, any de- 
parture from a regularly progressive return to health. 

In all cases of scarlatinous dropsy, the patient ought to be put 
to bed at once, and kept there throughout the acute period of the 
disease. The diet should be restricted to fluids. Milk and animal 
broths or farinaceous preparations alone ought to be allowed. The 
patient should be encouraged to drink freely and often of water, 
lemonade, or orangeade, or sweet spirit of nitre and water. A hot 
bath, used once or twice a day, is, we think, an excellent remedy 
in the early stage. It is best used in the following mode : A portable 
bath-tub should be brought into the bedroom, if possible. This can 
always be done in the cases of young children. The water ought to be 
warm — 96° to 98° or 100°. The patient ought to be fully immersed 
and kept in the water from ten to thirty minutes, the time being regu- 
lated by the degree of willingness of the child to remain, and by the 
effect of the bath on the system at large, as shown by the countenance 
and circulation. A soft cotton sheet is to be heated at the fire, and in 
this, when the patient is removed from the bath, he is to be carefully 
wrapped. Over this is to be put a light blanket, and thus wrapped in the 
two coverings, the child is to be laid in bed, or held in the arms, for half 
an hour or an hour. By this procedure sweating is generally induced. 
When this is over, the sheet and blanket may be removed and the 
child dressed in warm bedclothes again. The bath, carefully used in 
this way, once a day in slight cases, and twice or even three times 
in severe ones, has proved in our hands a most useful and soothing- 
remedy. 

In mild cases, without fever, the bowels ought to be kept soluble, no 
medicine being needed if thej^ are moved spontaneously. If they are 
not, a little syrup of rhubarb or Eochelle salts will be all-sufficient. If 
the amount of urine is scanty, a diuretic ought to be used. The follow- 
incr combination is excellent: 



R.— Potass. Bitart., 

Spts. Junip. Comp., 
Spts. ^ther. Nitros., 
Syrup. Simp., . 
Aq. Fluvial., . 

Give a teaspoonful every two hours. 



f^ij- 

fgv. 

fjij-- 



-M. 



In more severe cases, when vomiting, fever, anorexia, restlessness, 
rapid anasarca, scanty and dark-colored urine with blood, blood and 
granular casts, and a large proportion of albumen, all demonstrate a 
serious and extensive catarrh of the renal tubules, it is proper to use 
dry cupping to the loins, or in subjects of vigorous constitution, unin- 
jured by the previous scarlet fever, we may take three or four ounces 
of blood from the loins by wet cups. If the cupping cannot be used, 
hot cataplasms of Indian mush or flaxseed or bags of hot sand should 
be applied from time to time over the loins. The bowels ought to be 



PROPHYLACTIC TREATMENT. 757 

kept open by rhubarb, Eochelle salts, or Seidlitz powder. A febrifuge 
aud diuretic, such as the following, must be used : 

R.— Potass. Acetat., ^ . • ^j- 

Tinct. Digitalis, ........ f^ss. 

Syrup. Scillse, f3J vel f^ij. 

" Zingib., f^v, 

Aquaj, ......... ad f^iij. — M. 

Give a teaspoonful every two or three hours to children two or three years old. 
For those above that age the proportion of the active ingredients should be doubled. 

By these means the case should be treated for several days, until the 
fever subsides and the patient is no longer in present danger. When 
the fever is over, it is best to continue the above mixture, or something 
of the same kind, at longer intervals, and to give also one of the prep- 
arations of iron. Our own favorite is the mixture of muriated tincture 
of iron with acetic acid and spirit of Mindererus, or the simple tinc- 
ture itself, in doses of from two and a half to five drops, according to 
the age. three or four time's a day. If from any cause the tincture can- 
not be taken, wine of iron, or ferrated elixir of Calisaya bark, may be 
substituted, in half-drachm or drachm doses. 

As the fever disappears, the food ought to be increased. This is, of 
course, more impoi'tant than drugs, and ought to be strictly attended 
to by the physician himself at each visit. In some instances the most 
perverse irritability of the stomach attends the case for several days, 
so that the patient may almost or actually die of exhaustion. In such 
cases it is worse than folly to give drugs which are resisted with loath- 
ing, and vomited the instant they enter the stomach. Something must 
be chosen which at least does not clearly cause vomiting by its smell 
or taste. A mixture of wine of iron with syrup of tolu and some aro- 
matic water, chocolate and iron lozenges, or powdered metallic iron 
with white sugar, can often be taken even in these cases. A weak 
cream of tartar lemonade, flavored with lemon-juice, sweet spirit of 
nitre in lemonade, watermelon-seed tea, and such remedies may be 
used. In regard to details, as to the best method of feeding in such 
cases — on which, we desire to say, much more depends than upon 
drugs — we must refer the reader to the remarks on diet in obstinate 
sick stomach in chronic diarrhoea, at page 414. We venture to hope 
that we have seen lives saved in cases of this kind by constant atten- 
tion to little details of food and medicine, which must have been lost 
by an}' less constant care. In one instance the child was almost coma- 
tose, with total suppression of urine for five days, and the stomach so 
irritable that no remedy scarcely could be borne. Finally, under small 
doses of watermelon-seed tea, given frequently, mustard foot-baths, 
blisters behind the ears, and feeding with lime-water, milk and brandy, 
wine whey, chicken tea, and such preparations, the patient recovered. 

Prophylactic Treatment. — It was formerly asserted that belladonna, 
used by persons exposed to the contagion of scarlet fever, had the power 
of imparting perfect or nearly perfect immunity from its attack. The 



758 MEASLES. 

evident difficulty of determining a question such as this, in reference to 
a disease so uncertain and irregular in its mode of extension as scarla- 
tina, long maintained a certain degree of doubt as to the possibility of 
the truth of this most unlikely assertion. We believe, however, that, 
by common consent, all belief in the supposed efficacy of belladonna for 
this purpose has now been abandoned. 

In order to purify articles which have been exposed to scarlatina, 
they should be either put in boiling water or exposed to a temperature 
of over 200°, as we have seen that a temperature somewhat below the 
boiling-point of water destroys the activity of the virus. 



AETICLE YI. 

MEASLES, RUBEOLA, OR MORBILLI. 

Definition; Frequency; Forms. — Measles are an epidemic and con- 
tagious exantheme, characterized b}' catarrhal symptoms, continued 
fever, and an eruption, generally on the fourth day, of a crimson rash, 
in the form of stigmatized dots, like flea-bites, slightly elevated, which 
coalesce into irregular circles or crescents. It ends about the seventh 
day by desquamation. 

The frequenc}^ of the disease is very irregular in different years, be- 
cause of its epidemic nature. Thus, according to the mortality tables 
of the Board of Health, there have been 2279 deaths from measles in 
this city during the sixty years ending with 1870. In five of these 
years, as will be seen by a reference to the table at page 694, there is 
not a death recorded from this cause, while, on the other hand, the 
annual mortality exceeds 100 in eleven years, and 200 in two. During 
the same period, the deaths from scarlatina in this city, as already 
stated, amounted to 13,016. 

Measles are probably a more common though a less fatal disease, and 
attack a larger number of persons than scarlet fever; thus, during a 
period of fifteen years, we bave met with 314 cases of the former to 
263 of the latter. 

We shall describe two forms of the disease; the regular ov rubeola vul- 
garis ; and the malignant or rubeola maligna. We shall afterwards treat 
of its irregularities and complications. 

Causes. — A chief cause of the disease is epidemic influence. Of this 
there can be no doubt, as it is proved by the evidence of all observers. 

Contagion. — That it is a contagious disease is universally admitted. 
The contagious quality is thought to begin with the primarj- fever, and 
to continue up to the period of desquamation, though some authorities 
believe that it is also contagious during the stage of incubation. The 
precise period at which it ceases is not however known. The disease 



CAUSES. 759 

may be carried in fomites. It has been propagated also by inoculation 
with the blood taken from a patient, and with serum obtained from the 
vesicles which sometimes accompan}' the eruption. 

The period of incubation is difficult to determine, but is usually stated 
as from five or six, to twenty daj^s. or even longer. In the great ma- 
jority of cases, however, the eruption appears in from twelve to fifteen 
days after exposure to the contagion, thus making the duration of the 
period of incubation Irom nine to twelve daj^s. Thus, in 12 cases where 
we were able to determine with precision the interval between the ex- 
posure to contagion and the appearance of the rash, it was ten days in 
1 .case, eleven in 1, twelve in 3, thirteen in 5, fourteen in 1, and fifteen 
in 1. In 108 cases observed by M. Girard, of Marseilles (quoted in 
Med. Times and Gaz., Aug. 21, 1869, p. 225), the eruption appeared as 
late as the sixteenth day only in 3 cases; in all the others it was devel- 
oped on the thirteenth or fourteenth day, never before the thirteenth, 
and never after the sixteenth. 

MM. Rilliet and Barthez conclude that measles are more frequent, 
less contagious, and have longer incubative and prodromic stages than 
scarlet fever. 

The same authors are of opinion that variola is somewhat more rare, 
rather more contagious, and that its period of incubation and its pro- 
dromic stage are a little shorter than those of measles. 

Measles, like other contagious diseases, rarely occur a second time in 
the same individual. 

Age. — We find by uniting Dr. Emerson's tables with some given by 
Dr. Condie {Bis. of Child., note, p. 100), that the disease appears to be 
most frequent between the age of one and two years, for while 395 
deaths occurred in the second year, only 468 occurred between two and 
five years of age. This does not agree, however, with our own expe- 
rience, since of 280 cases of the disease that have come under our own 
observation, in which the age was accurately recorded, only 36 occurred 
in the second year, while 84: occurred between the end of the second 
and the end of the fifth year. This discrepancy depends probably, in 
part at least, on the greater mortality of the disease during the earliest 
years of life, which would of course give a larger number of deaths for 
those attacked in the second, than for those in the third, fourth, and 
fifth years. The cases that have come under our own observation oc- 
curred as follows. They are stated in their order of frequency. In 
the sixth year, 37; in the second, 36; in the seventh, 35; in the fifth, 
34; in the fourth, 30; in the eighth, 27; in the first, 19; in the ninth, 
11; and then in the eleventh, tenth, thirteenth, twelfth, and fifteenth. 

Sex. — It appears to be more common in the male than in the female 
sex. Of 290 cases that we have seen, in which the sex was noted, 156 
occurred in males, and 134 in females. 

Fungous origin. — In 1862, Dr. Salisbury, of Ohio (Amer. Jour, of 3Ied. 
Sciences, July and October, 1862), published two elaborate articles, in 
which he attributed measles to the action of the fungus developed on 
damp, mouldy straw. He reported the results of numerous cases in 



760 MEASLES. 

which this fungus had been inoculated with the production of a modified 
form of rubeola, which, however, protects the system against a future 
attack of true measles; and also instances where measles had broken 
out in camps where damp straw was used for bedding. 

A complete examination of this question, embodying the evidence of 
Dr. Woodward {Camp 'Diseases of the U. S. Armies^ Philadelphia, 1863), 
and the experiments of Dr. C. E. Smith, and one of ourselves, will be 
found in a paper by Dr. H. C. Wood, Jr., in The American Journal of 
the Medical Sciences, October, 1868, p. 342. 

The results of the inoculation of nearly 50 cases, prove that in nearh^ 
everj^ instance, the introduction of the straw fungus into the system is 
entirely without effect; and that in the few cases where any sjmiptoms 
have followed, they have not been those of true rubeola, nor have they 
protected the system from an attack of genuine measles. 

In regard to the occurrence of camp measles also, Dr. Woodward re- 
marks, that it prevailed almost exclusively in regiments raised in the 
rural districts, while those from cities aod towns were more or less com- 
pletely exempt; and that the inevitable inference from this, confirmed 
\>j personal inquiry, is that the recruits from the country had generally 
escaped the disease before their enlistment^ while those from towns had 
usually suffered from it at some previous period ; a condition of things 
entirely at variance with the idea that the straw fungus is the veritable 
cause of measles. 

Symptoms; Course; Duration. — Regular form of the disease. — Stage 
of invasion. — Measles begin with languor, irritability, sometimes chilli- 
ness, anorexia, aching in the back and limbs, fever, thirst, headache, 
and various signs of irritation of the mucous membrane of the eyes, 
nose, fauces, and larynx. 

The chilliness or horripilations which are mentioned by almost all 
writers are difficult to appreciate in children. We have seldom known 
the child itself to complain of them, but upon inquiry of the mother or 
nurse, have sometimes been told that they had observed some coolness 
of the hands or feet, or a disposition to keep near the fire, and a desire 
for additional clothing. These, therefore, are not important symptoms. 
IS'either is the aching in the back and limbs, as it is seldom complained 
of, and can be ascertained in the older only by close questioning, or 
suspected in the younger by their complaining when they are moved. 
Fever is very rarely absent. It almost always comes on with, or very 
soon after the other prodromes, but in rare cases does not begin until 
the second day. It is almost invariably continued, after it once begins, 
except that it remits somewhat about daylight and in the early part of 
the morning, to become exacerbated again in the after-part of the day. 
Its intensity increases, and the remissions become less distinct and 
shorter, as the time for the appearance of the eruption approaches. The 
pulse is increased in frequency, force, and volume, but rarely attains 
the same rapidity as in scarlet fever. At the same time the skin be- 
comes warm and dry, the f\ice is generally flushed, and there is consider- 
able restlessness and irritability at first, often passing into quiet and 



SYMPTOMS. 761 

drowsiness as the eruptive point approaches. The fever is accompanied 
by thirst, partial or complete anorexia, and generally by headache, 
which is frontal, and often complained of b}^ children old enough to give 
an account of their sensations. 

Vomiting occurs sometimes, but not as a general rule. The catar- 
rhal symptoms commence with, or may even precede the fever. They 
constitute the most characteristic early symptoms of the disease, and 
indeed the only ones by which we are able to distinguish it with any 
certainty in the first stage. They consist of irritation and redness of the 
conjunctivae, especially that of the ej^elids, lachrymation, suffusion of the 
eyes, sensibility to light, stuffing of the nose, coryza, sneezing, slight 
soreness of the throat, cough, some constriction of the thorax, and slight 
dyspncBa. The state of the eyes and nose are very important as signs 
of the disease. The above symptoms are not always present in the 
same degree, being very strongly marked in some instances, in others 
less so, and in some rare cases, absent. They are important, because 
there are few cases of ordinary cold in which they are present to the 
same extent, or if so, the accompanying general symptoms are slight 
compared with those of measles. We have rarely known the faucial 
affection severe enough to elicit complaints, and never to produce dif- 
ficult}' of deglutition. It consists generally only of slight redness of 
the tonsils, soft palate, and pharynx, which is most strongly marked 
about the time that the eruption makes its appearance. The cough 
usually appears on the first day. Infrequent and slight at first, it be^ 
comes more troublesome as the case progresses, until it assumes, on the 
third or fourth day, a character which is peculiar, and which may often 
lead to a suspicion as to the true nature of the attack. It is laryngeal, 
hard, dry, rather hoarse, and occurs generally in short paroxysms. 
Expectoration, if present at all, is slight, and consists of a clear, viscid 
mucus. At the same time the voice is often hoarse. 

The tongue is usually w4iite and somewhat furred; the bowels re- 
main in their natural condition, or there may be slight constipation or 
diarrhoea. Constipation is most frequent, according to our own expe- 
rience. The drowsiness, to which we have already alluded, often ex- 
ists during the first stage. We have noticed it in a great many cases. 
The child, if undisturbed, sleeps quietly for many hours, or for the 
greater part of one or two days, waking only from time to time to ask 
for drink, and then sinking off to sleep again. So common is this symp- 
tom that old nurses have a saying, — " The child is sleeping for the 
measles." The symptom is not alarming, unless it be connected with 
others which indicate local disease, or unless it pass into coma, or al- 
ternate with marked delirium. Other nervous symptoms which some- 
times occur, especially when the fever is violent, are restlessness, 
irritability, occasionally delirium at night, and, in very rare cases, con- 
vulsions. Of 167 cases observed by Eilliet and Barthez, the latter symp- 
tom appeared in the first stage only in one, and was then confined to 
the eyeballs. We have met with convulsions in 5 out of 314 cases, at 
the beginning of the eruption, and in one, of w4iich w^e shall not now 



762 MEASLES. 

speiik, at the close of the eruption. In one of the cases the convul- 
sions occurred on the first day, in a boy five years of as^e, of nervous 
temperament, and who had had several convulsive attacks during the 
process of dentition. The convulsions were general, but slight; they 
lasted only a short time, and were not followed by any bad consequences. 
In the second case the sickness began with fever, drowsiness, tremu- 
lous movements of the hands, delirium, and in a few hours a slight gen- 
eral convulsion. On the second day there were two attacks of convul- 
sions, both, however, slight. The other symptoms continued as before. 
On the third day the child was better, the fever having diminished, and 
the nervous symptoms in great measure disappeared. On the fourth, 
fifth, and sixth days, the fever returned, and on the middle of the sixth 
day, a full measles rash made its appearance. There was no recurrence 
of the nervous symptoms, and the case ended favorably. The third 
case occurred in a boy between seven and eight years old, of nervous 
and impressible temperament. The convulsive seizure took place just 
as the rash was coming out; it was very slight, and lasted not more 
than one or two minutes. In the fourth case, in a boy in the second 
year of life, who had already had three convulsive attacks from other 
causes, showing thereby a manifest predisposition to that kind of dis- 
order, the convulsions occurred as in the previous case, just at the com- 
ing out of the eruption. In this case also the convulsions were slight, 
lasting only a few minutes. In neither of these two cases were the 
convulsions followed b}^ dangerous symptoms. In the fifth and last 
case, the convulsions, as in the two preceding examples, occurred just 
as the rash was appearing; they were very slight, and were followed 
by no serious consequences. The subject of this case was a girl between 
seven and eight years old, who had previously had an attack of convul- 
sions produced by a severe febrile reaction occasioned by simple angina, 
and another attack, caused by indigestion. 

MM. Guersant and Blache (^Dict. de 3Ied., t. 27, p. 658) mention another 
initial symptom, which has sometimes enabled them to recognize the 
approach of measles before the eruption. This is a peculiar redness, a 
rose-colored punctation, of the roof of the mouth, soft palate, and 
nvula, differing from that of scarlatina. "We have observed this symp- 
tom ourselves in quite a number of cases, and, as it not unfrequently 
appears twenty-four hours before the cutaneous eruption has come out, 
we think that it is of some value as a sign in the early stages. 

M. Girard (loc. cit.) states that the early diagnosis may be aided by 
the fact, that a red papule appears near the free border of the velum 
palati several days before the appearance of the eruption. 

The duration of the initial stage is generally from three to four days. 
In a large majority of the cases that we have seen, the eruption has 
begun to appear in the course of the fourth day. This stage may, how- 
ever, last only one or two days, or be prolonged to five, six, or seven, 
and according to Guersant and Blache {loc. cit., p. 659), it lasted in one 
case, with all the characteristic symptoms, fifteen days. In a case that 
occurred to one of ourselves, the subject of which was a girl between 



SYMPTOMS. 763 

one and two years old, the eruption, owing no doubt to the presence of 
severe general bronchitis, did not make its appearance until the ninth 
day of the sickness, and even then came out slowly and with much dif- 
ficulty. The disease was known to be approaching from the fact that 
another child in the house had just recovered from an attack. In another 
case, in a girl between twelve and thirteen years of age, the eruption 
began on the fourth day of the sickness, but was so faint and indistinct 
that we could not, until the sixth day, feel sure that it was a measles 
rash. Even after this, the eruption continued pale and insufficient until 
the seventh day of the eruption, when it was out fully and completely. 

Second Stage, or that of Eruption. — The eruption generally appears 
some time in the course of the fourth day, showing itself first on the 
chin or cheeks, or some other part of the face, and extending gradually 
to the neck and trunk, and finally to the extremities. It is often com- 
pleted in from twenty-four to forty-eight hours. It begins in the form 
of distinct spots, not unlike flea-bites, of a more or less bright rose or 
crimson color, verging sometimes towards a deep red, of a roundish 
shape, with irregular edges, and of diiferent sizes, varying between half 
a line and three lines in diameter. When fully formed they constitute 
true papules, which are felt to be slightly elevated and firm to the touch, 
with broad, flat summits. When pressed upon, their color disappears, to 
return rapidly when the pressure is removed. Distinct and scanty at 
first, the spots or stigmata soon become more numerous, and arrange 
themselves into clusters of an irregularly crescentic or semilunar shape. 
The number of these clusters and the consequent general tint of the 
skin, depend upon the amount and intensity of the eruption. In very 
mild cases, or when the eruption is imperfect, the clusters of papules 
are few in number, and they are separated by large portions of healthy 
skin. In severe cases, on the contrary, the patches are so numerous, 
and coalesce so closely, that the skin assumes a general deep-red tint. 
Occasionally in these severe cases minute vesicles form on the summit 
of the papules. Yet it ought to be remarked that it can be observed on 
close examination that the papules never run completely into each other, 
so as to form a continuous red surface, unless it be over very small spaces 
and on certain parts of the surface, more particularly the face. 

The fever does not diminish when the eruption makes its appearance, 
and it sometimes augments, so that the highest temperature of the 
attack is usually attained soon after its full development. The skin 
retains its heat; the irritation of the eyes continues and is sometimes 
very severe; the nostrils are dry and incrusted, or there is coryza, and 
in some few cases epistaxis. The face is at the same time flushed, in- 
dependently of the eruption, the red color of the skin being observable 
in the intervals between the papules, and it looks swelled and turgid, 
from tumefaction of the cheeks and particularly of the ej^elids. The 
cough continues, and is loud, hoarse, and frequent in most cases, but in 
others short, scarcely hoarse, and but slightly marked. The voice is 
usually but not always a little hoarse. The respiration is slightly 
quickened in regular cases, but generally very little beyond the natural 



764 MEASLES. 

rate. The pulse is accelerated, though to a less degree than in scarla- 
tina: its frequency is usually found to be in direct proportion to the 
height of the temperature. The tongue is covered with a yellowish or 
whitish fur in its middle, while the edges and tip are clean and red. It 
remains moist and soft unless some complication occurs. The tonsils, 
soft palate, and pharjmx, present considerable redness, without tume- 
faction. The abdomen commonly remains natural, though in some few 
cases there is slight soreness over its whole extent or in the iliac fossae. 
Slight diarrhoea often occurs at this time. It seldom lasts more than 
from one to three days. In other cases the stools are natural, or there 
may be moderate constipation. The anorexia and thirst continue up to 
the stage of decline. About the time of the appearance of the rash 
there is often considerable restlessness, anxiety, starting and twitching 
in sleep, slight delirium, and in children old enough to describe their 
sensations, complaints of headache. The strength of the j)atient is not 
decidedly affected in most of the cases. 

The urine during this stage is scanty, of dark -yellow color, and not 
rarely contains a trace of albumen. 

Stage of Decline and Desquamation. — The disease having reached its 
height in the course of the sixth day, the second of the eruption, it re- 
mains nearly stationary for one or two da^^s longer, and begins to sub- 
side about the seventh or eighth of the disease, or third or fourth of the 
eruption. The eruption fades first on the face and neck, and has often 
very much or wholly subsided on those parts while it is still vivid on 
the extremities. The papules lose some of their color, become less prom- 
inent, diminish in size, and when pressed upon do not disappear entirely 
as the}^ did at first, but leave a dull or yellowish stain behind. A little 
later they assume a dirty yellow or copperish tint, which does not dis- 
appear under pressure, showing that a slight ecchymosis has taken place 
into the substance of the derm. These stains continue a variable 
length of time, and are finally removed by absorption. As the erup- 
tion disappears, a slight furfuraceous desquamation takes place in a 
considerable number of the cases, but not by any means in all. This 
begins usually about the face, and may either be limited to that part, 
or extend to other portions of the body. It is seldom general, how- 
ever, and is often scarcely noticeable. It occurs between the eighth 
and eleventh days of the disease, or fourth and seventh of the rash. 

From the moment the eruption passes its highest point of intensity, 
and begins to decline, the other symptoms do the same. The pulse fast 
loses in frequency, and regains its ordinary characters. The heat of 
skin passes away, often with considerable perspiration, but sometimes 
with gentle moisture only. The various catarrhal symptoms subside ; 
the cough is less frequent, loses its hoarseness, becomes softer, and 
gradually ceases. The expectoration, if present, now becomes more 
copious and thinner, and presents nummular masses of muco-purulent 
matter floating in a clear, watery fluid. The tongue cleans off; appetite 
returns; thirst ceases; the restlessness and irritability disaj)pear; and 
the child returns to its ordinary condition of health. 



TEMPERATURE — IRREGULARITIES. 765 

Temperature. — According to the observations of Ringer (^Reynolds' s 
Syst. of 3Ied., vol. i, art. Measles)^ the highest temperature reached in 
ordinary cases is about 103° F. From the observations of Roger (^op. 
cit.. p. 29S) this would appear higher than is usually attained, the mean 
of his records having been only 101.5° F. If it rises above 102.5° it indi- 
cates a severe, if it continues below this, a mild, attack. The tempera- 
ture presents the diurnal variations usual in fevers, until the close of 
the disease, when it suddenly declines. The duration of measles, 
measured by the temperature, varies considerably; the decline of the 
fever occurring in some cases on the fourth day, in others not until the 
eighth or tenth day. 

Irregularities of the Disease. — Under this term we shall describe 
only the anomalous symptoms of the disease, which occur independ- 
ently of comjDlications. Those which are produced by the latter causes 
will be fully treated of when we come to consider the subject of the 
complications. 

In some cases, the symptoms of the prodromic stage are so slight that 
they pass almost unobserved, and the child is scarcely thought to be 
sick until the rash makes its appearance. In others, owing to some 
peculiarity of the temperament, or to the state of the constitution at the 
time, they are much more severe than usual, or some one symptom may 
be in excess. In one case that came under our own observation, in a 
girl seven years old, the nausea and vomiting were very distressing, 
and were accompanied by the most intense frontal headache. She com- 
plained precisely as children generally do with tubercular meningitis, 
and was, moreover, extremely restless, and at night delirious. Never- 
theless, the eruption came out on the fourth day, and was perfectly 
regular in its characters and course; the unpleasant symptoms ceased 
from that moment, and the patient recovered without any further bad 
symptoms. We have already spoken of five cases accompanied by 
general convulsions at the commencement of the first stage. The course 
of the disease in the subsequent stages was regular in all respects. In 
two other cases, in girls, sisters, seven and nine years old respectively, 
of highly nervous temperament, the headache in the first stage was so 
intense as to require the application of leeches for its relief; yet the 
disease was regular in its other characters. 

The eruption presents various irregularities which ought to be noticed. 
It has already been stated that the amount of the rash varies according 
to the severity of the case, although in other respects regular. Some- 
times the papules are comparatively small in size and few in number, 
and consequently, the clusters in which they are arranged have con- 
siderable spaces of healthy skin between. When this is the case, the 
stigmata are usually rough, lighter in color, and from this circumstance 
and the fact that the spaces between the clusters are large, the general 
tint of the skin is much less deep than in severer cases, in which the 
opposite of these characters prevails. In some of the mildest cases, the 
amount of eruption upon the extremities has been very small, and after 
forming, it has very rapidly, in the space of a niglit, faded to such a 



766 MEASLES. 

degree as to seem almost a retrocession. Bat as this sudden disappear- 
ance has not been accompanied or followed by dangerous symptoms, it 
is clear that it was dependent simply on the mildness of the attack. In 
such instances the general syuiptoms have always been slight, and the 
whole duration of the sickness shorter by two or three days than in 
severer cases. At times the order of appearance of the eruption is re- 
versed, and the papules appear first on the trunk, thence spreading to 
the face. 

We have already described the dull yellowish stains which remain 
after the papules have faded. These stains sometimes assume, in ma- 
lignant cases, a livid or purplish hue, from the occurrence of passive 
hemorrhage into the tissue of the derm. They may, however, assume 
a dark and purpureous appearance, without any malignant or danger- 
ous symptoms whatever. This happened in a family in which one of 
us attended seven cases of the disease in 1845. In three of them (boys 
of 10, 5, and 1 year old, respectively), the eruption, which was copious 
and regular in all, became in a single night, at the moment of decline, 
of a dark brown or light purple hue. The spots did not disappear at 
all under pressure, and were evidently formed by true ecchymoses. 
The general symptoms were all favorable. The only peculiarity to be 
observed was that the fever had disappeared very suddenly, and that 
the extremities were slightly cooler than natural. The convalescence 
was as usual, except that the ecchymotic spots disappeared very slowly 
and gradually. We have, since the above-named period, seen a great 
many similar cases, but in none have the symptoms been attended or 
followed by any evil consequences. 

Several authors describe a form of measles without eruption. They 
state that during the epidemic prevalence of the disease, some children 
present all the catarrhal and febrile symptoms, without the eruption, 
and that they are protected against future attacks. The last assertion, 
at least, must be very difficult to prove. For our own part, we have 
never met with such cases, and should we ever seem to do so, would 
certainly not call them measles, lest by so doing the parents might be 
induced, on future occasions, to expose the child unnecessarily to the 
disease, when, should any evil consequences follow, they might justly 
question the wisdom of the physician's advice. 

Willan and other authors have described another variety of the dis- 
ease, to which is applied the term rubeola sine catarrho, or measles 
without catarrhal symptoms. Such cases are said to present no catar- 
rhal 63'mptoms whatever, and little or no febrile reaction. They are 
stated, moreover, to occur generally during the epidemic prevalence of 
measles. Most authors agree that this form does not protect the con- 
stitution against the true disease, and some regard it only as an erup- 
tion resembling measles, dependent upon gastric disorder. Our own 
opinion is that such cases, of which we have seen a considerable 
number, are nothing more than examples of roseola. The entire ab- 
sence of catarrhal symptoms and of fever, or their very slight charac- 
ter, the short duration of the cases, and the little constitutional disturb- 



MALIGNANT FORM — COMPLICATIONS. 76T 

ance exhibited bj' the patient, all serve to convince us that they cannot 
be attacks of true measles. ^Ye recollect three such cases in particu- 
lar, which, had they been accompanied by cough and fever, we should 
certainly have called measles. They all occurred in infants. The rash 
was preceded for two or three days by feverishness, uneasiness, rest- 
lessness during sleep, and slight diarrhoea, after which the eruption 
suddenly made its appearance and covered the whole integument 
within twenty-four hours. There were no catarrhal symptoms what- 
ever. At the same time the febrile symptoms disappeared, and the 
children seemed quite well. The eruption never lasted over forty- 
eight hours, and disappeared without leaving a trace behind. They 
were, no doubt, cases of roseola. 

EuBEOLA Maligna. — This form may occur either as an epidemic or 
sporadic affection. Generally, however, it prevails as an epidemic, and 
depends upon some peculiarity which it is impossible to understand. 
The few sporadic cases which are met with, may be traced generally 
to some vicious state of the constitution of the individual, or to the 
unfavorable hygienic conditions in w^hich he is placed. The symp- 
toms assume ataxic or adynamic characters, which give to tlie case 
the features of the typhoid type of disease. They may make their ap- 
pearance in the prodromic, or, as happens more frequently, not before 
the eruptive stage. ^Yhen the}^ begin in the first stage, the case is 
marked by great frequency and feebleness of the pulse; by prostra- 
tion; by unusual dyspnoea and oppression; and especially by greater 
violence of the nervous symptoms, as delirium or stupor. Sometimes, 
even in this stage, petechiae make their appearance, and there is lividity 
and soreness of the fauces, with discharges of dark blood from the nos- 
trils, and sometimes profuse and exhausting diarrhoea or d^^senteric 
discharges. When the time for the eruption to appear arrives, this 
comes out slowly and imperfectly, or irregularly, and generall}^ assumes 
a livid, purplish, or blackish color, owing to the passive exudation of 
blood into the papules, and hence the name sometimes given to such 
cases, of Rubeola Nigra^ or black measles. 

This form of the disease assumes, in fact, many of the features of 
purpura hemorrhagica. The patient may die of exhaustion, of conges- 
tion of some important organ, as the brain or lungs, of the diarrhoea or 
dysentery which sometimes complicate the disease, or finally of the 
hemorrhages which occur in consequence of the dissolved and fluid state 
of the blood; or he may, after a severe struggle with the disease, re- 
cover his health. 

Complications and Sequels. — MM. Rilliet and Barthez begin their 
chapter on the complications of this disease with the following excellent 
remarks: " Eubeola manifests itself by an inflammation or inflamma- 
tory fluxion upon the skin and mucous membranes. The regular course 
of the disease depends upon the conservation of a due equilibrium be- 
tween these two kinds of fluxions. That which is seated in the skin 
ought in general to predominate : if the equilibrium be destroyed by 
any cause whatever, whether accidental or inherent to the disease, and 



768 MEASLES. 

should the predominance of the inflammation take place in the mucous 
membranes, there will result a phlegmasia of some one of those tissues. 

"It is easy to foresee, b}^ attention to these circumstances, that the 
inflammatory complications of measles will be most apt to fall upon 
the mucous membranes, and that broncho-pneumonia, pharyn go-laryn- 
gitis, and intestinal inflammations will be the most frequent of all." 

Bronchitis and Pneumonia. — These constitute by far the most frequent 
and important complications of measles. In 167 cases, MM. Eilliet and 
Barthez met with 24 cases of bronchitis, 7 of pneumonia without bron- 
chitis, and 58 of lobular broncho-pneumonia. This statement shows how 
very large a proportion of the cases of measles occurring in the Chil- 
dren's Hospital at Paris, became complicated in the course of the 
attack. The proportion in private practice is much smaller, since in 
314 cases, we have met with only 24 of bronchitis, and 6 of lobar pneu- 
monia. These are, however, in private practice, according to our ex- 
perience, much the most important of the complications likely to occur. 
Of six deaths which occurred in the 314 cases that ^ve have seen, 3 were 
caused by bronchitis. 

The time at which these different complications make their appear- 
ance is important. They may occur during the initial stage, early in 
the eruptive stage, during the decline of the eruption, or after the erup- 
tion. The most common period for their occurrence is the initial stage. 
It is diflicult or impossible to ascertain their causes in a great many 
cases. In some instances they depend evidently upon cold. Age has 
some influence upon their production, as bronchitis is most apt to occur 
in young children, whilst lobar pneumonia attacks those who are older. 

The physical signs of these affections are the same as when they exist 
in the idiopathic form. The rational signs are increase of cough, which, 
instead of being merely laryngeal, becomes deeper and either pneumonic 
or catarrhal ; and dyspnoea, w^hich is sometimes excessive, the number 
of respirations mounting to 40, 50, and, in severe cases, to 60 and 80. 
The pulse is more frequent than in regular measles, and in very bad 
cases becomes rapid and small -, the skin is hot and dry ; the face is pale 
and anxious in severe cases, in which the eruption does not appear; 
and the child is generally restless and irritable, with broken irregular 
sleep, or, in the most violent cases, it is dull and soporose. In two of 
the fatal cases that came under our observation, convulsions occurred. 
It should be remarked, however, that in one, the patient, a boy only 
nine months old, was laboring under an attack of hooping-cough, and 
that it was in one of the paroxysms of that malady that death took 
place. In the other case, that of a boy eighteen months old, the con- 
vulsions occurred first on the day of eruption, and then ceased, to recur 
again the third daj^ afterwards. The bronchitis dated from before the 
appearance of the eruption, and was no doubt the cause of the convul- 
sions and death. 

When a pulmonary complication begins in the prodromic stage, it 
almost always modifies the eruption in some manner, either retarding 
or rendering it irregular or imperfect. When it dates from the second 



COMPLICATIONS. 769 

stage, it may cause a partial or complete retrocession of the eruption. 
We have known the eruption to be retarded several days, so as not to 
come out until the fifth, sixth, or even ninth. When the rash does ap- 
pear, whether at the usual period or later, it is evidently with difficulty. 
It is pale and scanty, or abundant on one part of the body, and scanty on 
another, or it appears and disappears alternately. At length it either 
comes out fully, and the threatening symptoms pass away, or the erup- 
tion lasts the usual, or nearly the usual length of time, in its pale and 
imperfect condition, and the child recovers slowly and gradually from 
the complication, which has become the most important part of the 
sickness; or, in fatal cases, the sj'mptoms grow worse and worse, and 
the child dies after a few days, or a longer time, according as the in- 
flammation assumes the acute or chronic type. 

Whenever it is observed in a case of measles, that there is more drow- 
siness or irritability than usual, or that the pulse is more frequent or 
stronger than it ought to be, it becomes important to ascertain carefully 
the state of the respiration. If this be accelerated, the thorax ought 
to be examined with strict attention, by auscultation and percussion, to 
discover whether there be not some pulmonic inflammation at work, 
likely to convert the disorder from a mild one, as it almost always is 
when uncomplicated, into one dangerous to life, which it will assuredly 
become, should any j^ulmonic complication be allowed to steal unawares 
upon the patient. 

The prognosis of the pulmonic complications of measles would ap- 
pear to be very unfavorable in hospitals for children, since Eilliet and 
Barthez state that scarcely one patient in four or five recovered. Of 
the 30 cases that we have seen, we have already stated that 3 died of 
bronchitis, and if we recollect that one of these w^as complicated also 
with pertussis and morbid dentition, it will be seen that the prognosis 
is, as might be expected, vastly more favorable in private than in hos- 
pital practice. 

There is, however, a tendency, especially marked in delicate, stru- 
mous children, for the inflammation of the bronchial mucous membrane 
to become chronic, in which case the cough may persist for years, at 
times intermitting, but returning after the slightest exposure, and par- 
ticularly in cold, damp seasons of the year. 

Laryngitis is a common complication of the disease. The authors 
just quoted met with it in 35 of their 167 cases. It occurred in 8 of 
the 314 cases that came under our observation. It is often accompa- 
nied by pharyngitis. 

Autopsies show that the laryngitis may be slight, severe, or accom- 
panied with pseudo-membranous exudation. The inflammation may 
be simple, consisting merely of difl'erent degrees of redness, or of red- 
ness with thickening and softening of the mucous membrane; it may 
be more intense and accompanied by ulcerations or erosions; or, lastly, 
it may be associated with an exudation of false membrane. 

The symptoms of this complication will depend upon the form the 
inflammation assumes. It is unnecessary to describe them here, as 

49 



770 MEASLES. 

they are the same as those of the idiopathic affection, which has already 
been fully treated of. 

The occurrence of larj^ngitis exerts but little influence on the rash, 
particularly as it almost always appears during the decline of the latter. 
It is seldom fatal, unless it assume the pseudo-membranous form. The 
eight cases that came under our observation were attacks of the simple 
disease, and they all recovered. 

Inflammation of the Intestines. — According to Eilliet and Barthez, 
lesions of the intestinal mucous membrane are the most frequent com- 
plications, after pulmonary affections. About a third of their cases 
presented at the autopsy erythematous inflammation of the mucous 
membrane; a fifth offered follicular entero-colitis, a seventh ulcerative 
inflammation, and a fourth softening. Some presented several of the 
lesions united, and in a few no lesion was found, though the symptoms 
of entero-colitis had existed during life. We give these data from the 
above authors, not because they apply to private practice, but merely 
in order to show what are the tendencies of the disease, when disposed 
from unfavorable hygienic conditions to take on complications. We 
have met with only seven instances of intestinal inflammation in the 
314 cases that have come under our own observation. Four of these 
occurred in the same family, in children of seven^ five, three, and. one 
year old respectively. They were cases of entero-colitis, accompanied 
in two, with dysenteric symptoms, and all made their appearance to- 
wards the close of the disease. The three remaining cases were attacks 
of dysentery, one of which was \qyj severe, the stools amounting to 
twenty in the day. while the other two were much less so. 

The intestinal complications may appear during the initial stage, or 
on the daj' of eruption, but if not at one of these periods, they are most 
apt to -occur during the decline of the rash. The slight cases, consti- 
tuting the common diarrhoea of the disease, generally begin early, 
whilst the grave cases usually date from a later period of the disease. 
The causes of these complications seem to be various exciting agents 
acting upon a mucous membrane predisposed, by the nature of the dis- 
ease, to inflammatory action. These agents are said to be, generally, 
improper food, giving rise to indigestions; and the too earl}' use of 
purgative remedies, and laxatives. In the cases observed by ourselves 
it was impossible to detect the causes. 

The symptoms are more or less abundant diarrhcBa, and in some, but 
not all the cases, sensibility with tumidity and tension of the abdo- 
men. This complication does not exert much influence upon the mea- 
sles, which usually pursue their regular course. Sometimes, howev.er, 
it occasions an aggravation of the febrile symptoms, and, when of a 
grave character, may no doubt interfere with the regular progress of 
the eruptive disease. 

According to Eilliet and Barthez, this complication was very seldom 
the only, or even chief cause of a fatal termination. Scarcely five or 
six of all that they observed could be considered as of that kind. It 
increases very much, however, the danger of the pulmonic attacks, 



CASE. 771 

for the latter are much less serious, so long as they exist alone, while 
so soon as intestinal inflammation is added to them, they become almost 
necessarily fatal. The seven eases that we met with recovered under 
simple treatment. 

In a considerable number of cases, a slight diarrhoea, to which we have 
already referred as a common event in measles, occurred, but only in 
the seven above mentioned did it amount to a serious complication. 

In one case that came under our observation, in a girl between five 
and six years old, fatal cerebral symptoms, due either to congestion of 
the brain or ursemia, occurred just as the rash was disappearing. There 
was no evident cause whatever for this accident. There had been no 
imprudence either as to diet or exposure. The child was, however, of 
a tubercular family, the mother having at this very time tubercular 
disease of the lungs. The eruption had come out well and properly, 
and continued to do so on the second day without any irregular or 
threatening symptoms. On the third day of the eruption this began to 
decline, and the child had an attack of spontaneous vomiting, but con- 
tinued through the day cheerful and pleasant. The night of that day 
she was restless and feverish, and wanted much drink. On the fourth 
day she was drowsy and heav}", and complained of her head. We saw 
her first in the evening of this day. She was then very dull and heavy, 
scarcely answering questions, and protruding the tongue slowly and 
after much urging. She had some little, but not a troublesome cough. 
Careful examination revealed no disease of the thoracic organs. The 
respiration was natural, and the pulse full and very frequent. On the 
morning of the fifth day the patient was comatose, neither answering 
questions nor protruding her tongue. In the course of the day there 
were some irregular convulsive movements. In the evening the right 
arm was rigidly flexed at the elbow, and the left one stifiiy extended. 
The patient died that night. 

In another case death occurred from sudden effusion of serum into the 
internal cavities, caused apparently by the existence of an excessively 
hydrsemic state of the blood, possibly connected with albuminuria, 
which had been allowed to come on gradually, without any attempt on 
the part of the parents to seek a remedy during the slow approach of 
this condition of the circulating fluid. 

Case. The patient was a hoy in the second year of his age, who had a phthis- 
ical mother. The attack of measles took place in the last week of January, 1852, 
and was regular, and not, according to the account of the parents, we not having 
seen the child, at all severe or dangerous in any respect. After the attack was over, 
however, and though he was running about the house as before, he continued to look 
more and more pale and sickly until the evening of Februarj'^ 2.5th, when suddenly 
after 11 p.m., he was seized with fever, and became very restless. On the following 
day, at 9 a.m , we saw him. He was then extremely pallid, and very drowsy and 
heavy ; the breathing was rapid and oppressed, the pulse very frequent, and the skin 
hot and dry. He was evidently dropsical, as both the face and hands, and the feet 
also, were puffed, smooth, and doughy. The bowels had not been opened the previous 
night. In the evening the pulse was 170; the skin was still hot, and the breathing 
very rapid and much oppressed. There was scarcely any cough. The percussion was 



772 MEASLES. 

dull over too large a space in the prsecordial region ; the cardiac impulse was obscure, 
and the sounds indistinct and muffled ; there was no bellows-murmur. The percus- 
sion was dull over the inferior dorsal regions. No rale whatever was heard. The 
child died on the following morning at 3J o'clock. Ten minutes before his death he 
asked for a drink, lifted himself up in bed, drank freely, looked around intelligently, 
and then laid down and died. At the autopsy the subcutaneous cellular tissue was 
found to be infiltrated with serum. On puncturing the right pleural sac, there was 
an immediate escape of a clear, straw-yellow serum. There was considerable effu- 
sion in the left pleura also, but less than in the right. The pericardium contained at 
least two ounces of serum, so that it was pushed off to a considerable extent from the 
heart. There was a slight pleuritic adhesion of the upper lobe of the right lung to 
the ribs. This was, however, evidently of an ancient date. There was no other in- 
flammation of the pleuras, and none of the pericardium. Both lungs contained tu- 
bercles, which were not very numerous, but in the upper lobes of considerable size. 
There was no pneumonia, but both lungs were somewhat congested. The heart was 
larger than usual. In the right auricle there was a rather large, and white, but soft 
concretion, and a smaller one in the right ventricle. The left cavities presented no 
concretions. The valves were healthy. 

There are several other disorders which sometimes complicate or 
follow measles, but as we have alreadj^ given as much space to this 
subject as the limits of the work will allow, we shall be satisfied with 
a simple enumeration of them. They are otitis, ophthalmia, hemor- 
rhages, gangrene of the cheek or vulva, anasarca, and different cere- 
bral symptoms. We will merely add that measles are supposed by 
many observers to have a special tendency to develop tubercular dis- 
ease in the system, and that it is necessary, therefore, to treat a child 
showing any predisposition to that diathesis, or one born of tubercular 
parents, with particular caution, both at the time of the disease and 
during the convalescence. It is not uncommon for measles to be con- 
joined with other eruptive diseases. We have known it to coexist with 
scarlatina in two instances, and Dr. Gr. B. Wood has met with a fatal 
case of the same nature. It maj^ be associated likewise with variola or 
with erysipelas; of the latter we have met with one instance. We will 
mention here that of the whole 314 cases of measles that we have ob- 
served, 257 were simple and 57 complicated. The complications were 
as follows: bronchitis, 2-4; pneumonia, 6; laryngitis, slight or severe, 8; 
dysentery, 7; pertussis, 7; scarlatina, 2; convulsions in the early stage 
of the disease, 5, and in the latter stage, 3; keratitis, 2; intermittent 
fever, 1; erysipelas, 1; meningitis, 1; congestion of the brain, 1; serous 
effusion into the internal cavities, 1. It ought to be observed, however, 
that in the above enumeration several cases are referred to twice, and 
one, a case in which pertussis, bronchitis, and convulsions occurred, 
three times. 

Anatomical Lesions. — It is difficult to ascertain what are the char- 
acteristic lesions of measles, because of the fact that most of the fatal 
cases prove so in consequence of some complication. Some few fatal 
cases, however, of the regular form, and some in which the complica- 
tion was so slight as not to be likely to change the morbid appearances 
much, have led to the following conclusions. 

The lesions present in measles are the following: general congestion 



DIAGNOSIS. 773 

of different organs, whicL are colored red from the imbibition of blood 
and sometimes softened. The congestion affects the raucous membranes 
particularly, and imparts to them a reddish or slightly blackish coloi\ 
In some of the cases there is morbid development of the intestinal fol- 
licles. The most important lesion, however, is that of the blood, which 
presents the appearances common to the class of pyrexiee. These are 
normal proportion or diminution of the fibrinous, with increase of the 
globular element of the blood. Dr. Copland (^Dict. Frac. Med.^ vol. ii, 
p. 819) gives the appearances in a few fatal cases of malignant measles. 
They were, softening of the tissues and the facility with which they 
were torn ; the presence, in some of the cases, of a turbid or sanguine- 
ous serous fluid in the serous cavities; general congestion of the lungs; 
dark appearance, and livid or purple ecchymoses of the bronchial mu- 
cous surface, of the fauces, stomach, and caecum; engorgement with 
dark and semi-fluid blood of the veins and sinuses of the brain, and of 
the auricles and large veins; and finally a livid and mottled appearance 
of some parts of the body, with petechise of a dark color. 

Diagnosis. — It is impossible to diagnosticate measles in the first 
stage with any considerable certainty. The existence of the disease 
may be suspected in that period from the appearance of the eyes, from 
the coryza and sneezing, the frequent, hoarse, scraping cough, and the 
fever, headache, and thirst. If, in connection with these symptoms, it 
happens that an epidemic of measles be prevailing at the time, or that 
the child has been exposed to the contagion of the disease, the inference 
becomes still more plausible. Nevertheless, any opinion upon this point 
ouo'ht to be o;iven with much reservation. 

to O 

We have already alluded to the opinion of some authorities, that the 
diagnosis in the early stage is aided by the presence of punctated red- 
ness of the roof of the mouth, or of a red papule on the velum palati. 

After the eruption has come out fully, it is not likely to be mistaken 
for any other disease, unless it be roseola, the rash of which sometimes 
resembles that of measles very closely. It may be distinguished, how- 
ever, by attention to the concomitant symptoms, by the slight degree 
of fever, the more rapid evolution of the rash, and the absence of the 
peculiar catarrhal symptoms in roseola. In the very early stage of the 
eruption, measles may be confounded with variola. A careful attention, 
however, to the size and shape of the papules, which in measles are 
much larger, flatter, less elevated, softer, and without the shotty feel 
peculiar to the papules in variola, and the presence of the catarrhal 
symptoms, will usually suffice to distinguish them, even in the earliest 
stage. In measles also the general symptoms persist, or even become 
aggravated after the appearance of the eruption, instead of abruptly 
subsiding as they do in variola. A little later, the appearance of vesi- 
cles on some of the papules about the face in variola, will show the 
difference still more strongly. The distinction between measles and 
scarlatina has already been drawn in the description of the latter dis- 
ease. It rests chiefly on the much shorter duration of the prodromic 
stage, the greater violence of the anginose sj-mptoms, the absence of 



774 MEASLES. 

the peculiar catarrbal symptoms, and the more rapid evolution of the 
eruption in scarlet fever; and lastly, on the differences in the two 
eruptions, observable especially at their first appearance. 

The eruption of typhus fever appears nearly at the same time as 
that of measles, and in their earliest stage the two eruptions often re- 
semble each other closely. In typhus, however, there is an entire ab- 
sence of the characteristic catarrhal symptoms. The spots are less 
elevated; are isolated and round, instead of coalescing to form cres- 
centic patches; do not appear first on the face, but on the trunk or 
wrists (Ringer); more frequently become petechial, and last a much 
longer time. 

\yhen measles are conjoined with some other eruption, the diagnosis 
is to be made out by a careful study of the initial symptoms, and of the 
eruption on different parts of the body, for we can generally find well- 
marked patches of the rash peculiar to each on some portions of the 
surface. In one of the cases of measles and scarlatina that we saw, the 
latter disease was developed first. The eruption made its appearance 
in the usual form ; on the second day of the eruption, the child was 
seized with hard, hoarse, larj^ngeal cough, and with redness of the 
eyes and lachrymation. These symptoms continued three days, at the 
end of which time the scarlatinous rash had disappeared from the face, 
but remained visible upon the trunk and extremities. Characteristic 
measly papules now made their appearance on the face, and pursued 
their regular course, while on the trunk and extremities the measly 
eruption was never well defined, being mixed with and disguised, as it 
were, by that of the scarlatina. In the other case, the measles ap- 
peared first and went on regularly until the eruption was declining and 
the general symptoms moderating, when suddenly the fever, heat of 
skin, restlessness, and irritability returned, and the child was very soon 
covered with the punctated scarlet rash of scarlatina. 

Prognosis. — The prognosis of simple, uncomplicated measles is very 
favorable; the cases almost always recover without difficulty. This is 
shown to be true by the following facts : Eilliet and Earthez report 36 
cases of simple measles, of which all but one recovered. Of 257 cases 
that Ave have seen, all terminated favorably. When, on the contrary, 
complications occur, the disease always becomes more or less danger- 
ous, the degree of danger depending on the nature of the intercurrent 
affection, and on the hygienic conditions in which the patient is placed. 
Thus of 131 cases observed by the above authors, in which some form 
of complication occurred, 89 or about two-thirds proved fatal, while of 
the 53 complicated cases that we have seen, only 6 were fatal. It must 
be recollected that the cases of the French observers all occurred under 
the unfavorable hj^gienic conditions of a large hospital, in children of 
bad constitution from congenital or acquired causes, whilst ours were 
observed in private practice, where the hygienic conditions are favor- 
able in the same degree as they are unfavorable in hospitals. 

The six fatal cases that came under our observation, proved so from 
the circumstances we are about to mention. The first occurred in a 



PROGNOSIS. 775 

child nine months old, Avho was laboring under pertussis when attacked 
with nieasles. Bronchitis supervened upon the measles, and proved 
fatal by convulsions, which came on during a paroxysm of hooping- 
cough, two weeks after the disappearance of the rubeola. The second 
case was that of a boy, eighteen months old, who was prescribed for by 
an a2:)0thecary from behind his counter, until we saw him. The erup- 
tion made its appearance imperfectly, we were told, and with a con- 
vulsion. After this he was very restless, and had rapid and difficult 
respiration and much cough. On the morning of the fourth day of the 
eruption, this had almost entirely disappeared, and the child was again 
attacked with convulsions. We saw him shortly after this for the first 
time, and found him comatose, with convulsive movements of the limbs, 
extreme dyspnoea, and all the symptoms of extensive bronchitis of both 
lungs. He died thirty-six hours from this, as was to be expected. The 
third was a case of pneumonia in a child between one and two years of 
age, in which the inflammation came on as the eruption was fading, 
and proved fatal, in spite of all that could be done, on the eleventh 
day. The fourth occurred in a boy between four and five years old, 
who appeared to recover perfectly from the measles, but was attacked 
in ten days with meningitis, and died. The fifth was the case of con- 
gestion of the brain, already detailed in the remarks upon complica- 
tions, as 2)roving fatal shortly after the decline of the rash. The sixth 
was that of sudden dropsical effusion into the internal cavities, also de- 
scribed in the remarks upon complications. 

To conclude, we may state that the prognosis is always highly favor- 
able under the following circumstances: when the disease is primary; 
when the initial stage is of the proper duration ; when the eruption 
begins upon the face and extends gradually to the rest of the body; 
when the febrile movement is moderate; when the eruption, after in- 
creasing for one, two, or three days, gradually decreases; when the 
cough and other concomitant symptoms diminish with the fever; when 
the cutaneous surface, after the fading of the rash, assumes a natural 
color, and is neither flushed nor pale; when the appetite returns, the 
disposition to be amused and take notice continues, and lastl}^ when 
the sleep is natural. 

On the contrary, the prognosis becomes unfavorable under the fol- 
lowing circumstances : when the initial stage lasts longer than usual, 
and when it is accompanied b}^ violent symptoms of any kind, as ex- 
treme jactitation, irritability, dyspnoea, much stupor, coma, or convul- 
sions; when the eruption is irregular in its appearance or course; when 
the fever does not disappear with the eruption, whether it remains vio- 
lent or assume the form of hectic; when, after the eruption, the face 
continues deeply flushed or becomes very pale; when the cough, dj'sp- 
noea, or diarrhoea persist; and, lastly, when the child remains weak, 
languid, dispirited, or irritable. 

It may be stated, in conclusion, that the prognosis of measles is al- 
ways favorable in proportion to the health of the child at the time of 
the invasion, and the regularity with which the disease passes through 



776 MEASLES. 

its different phases; while it becomes unfavorable, though far less so 
in private practice amongst people in easy circumstances, than in hos- 
pitals or amongst the poor and wretched, whenever it attacks a child 
already laboring under some disease, and when it becomes complicated 
with any other maladj^, either local or general. 

Treatment of the Regular, Simple Form. — This form, requires, in 
a large majority of the cases, little other treatment than strict atten- 
tion to the hygienic condition of the patient, the use of simple diapho- 
retics, of mild cathartics occasionally, and the palliation of any of the 
sj^mptoms that may chance to become somewhat more troublesome 
than usual. 

The child ought to be confined as much as possible to bed in a large, 
well-ventilated chamber, the light in which should be somewhat soft- 
ened. Every precaution should be observed to prevent chilling of the 
body, while at the same time it is nearly, if not quite as important, to 
avoid overheating the patient, either by excessive clothing, or by keejo- 
ing the temperature of the room too high. In winter, it is well to di- 
rect the temperature to be maintained at between 68° and 70° F., night 
and day. If this be done, the child is not apt to take cold, even though 
it be uncovered at times, and yet the warmth is not oppressive. We 
have often remarked that this temperature is just what it ought to be 
when the room is well ventilated, either by means of an open fireplace, 
or by communication with adjoining rooms; but when, on the con- 
trary, the room is heated by a furnace-flue, and not ventilated at all, 
or very imperfectly, the same temperature, as indicated by the ther- 
mometer, becomes extremely close and oppressive. Under such cir- 
cumstances, a door into an adjoining room, or if this cannot be, one 
into the entry, ought to be kept more or less open, with a screen of 
some kind between it and the child, in order to secure a good ventilation, 
which is assuredly of the very highest importance, and yet to prevent 
by the screen a current of cool air from chilling the patient. Miss 
Florence Nightingale remarks that doors are made to be shut and 
windows to open. There is much in this saying, and, when the nurse 
is intelligent and observant, we much prefer to shut the door and open 
a window. In our winter temperatures in this city this must be done 
very carefully. One of the sashes raised an inch, or one or two inches, 
will make a large difference in the temperature and vitality of the air 
of the sick-room. 

The diet during the febrile period ought to be very light. It may 
consist of milk and water, of arrowroot, sago, or tapioca, prepared with 
milk or water; or of crackers soaked in water, with salt, or some sim- 
ilar food. When the eruption and fever have in great measure disap- 
peared, some light broth, either vegetable or animal, with dry toast or 
bread, plain boiled rice, a roasted potato, or ice cream, may be added; 
and after all the symptoms have ceased, the usual diet can be gradually 
resumed. The drinks may consist of simple water, of lemonade, orange- 
ade, gum-water, or flaxseed tea, with the addition of a little sweet nitre ; 
or of weak infusions of balm, sweet-marjoram, or saffron, or cascarilla 



TREATMENT. 777 

Avith a few drops of hydrochloric or nitric acids. They may be given 
in any reasonable quantity, at the temperature of the room. Some 
persons have a great dread of cold water in this disease. We have 
never seen small quantities (a Avineglassful or two at a time) of cold 
water do any harm, and believe it to be most useful and necessary 
when the fever is violent, and the heat very great. We once, however, 
saw a boy, nine years old, attacked with violent colic and partial retro- 
cession of the eruption, after swallowing suddenly a tumblerful of iced 
water. The unpleasant symptoms passed off in a few hours, and he 
had no difficulty afterwards. 

The patient should not be permitted to leave the room until a few 
days after the entire disappearance of the disease. This precaution is 
necessary- for all, but particularly for the delicate, and in the cold 
weather of these latitudes. He should be kept in the house until he 
has regained in some degree his usual health, and then sent out with 
due precautions. 

Medical Treatment. — Many cases of measles — the mild, the moderate, 
the uncomplicated — need no other treatment than that just laid down 
in the paragraph on the hygiene of the disease. So long as the case 
goes on regularly, so long as the symptoms are moderate and such as 
to cause but little suffering, there is no necessity for drugs, or, at the 
most, a simple diaphoretic, as sweet spirit of nitre or the solution of 
acetate of ammonia, with a little paregoric or laudanum once or twice 
in the eveninsr, will be all that ouo-ht to be done. 

The child does not require, and therefore ought not be made to take 
as a mere routine cathartics. If the bowels are known to be costive^ and- 
not to have been moved for two or three days, a teaspoonful or dessert- 
spoonful of castor oil, or, better still, a dessertspoonful to a tablespoon- 
ful of simple syrup of rhubarb, or a simple enema, will answer every 
l^urpose. We are sure that active purging is unnecessary, and aj^t to 
be hurtful. 

When the case is a very decided one, and the eruption extensive and 
deep in color, the fever runs high, and the patient often suffers greatly 
from the fever-pains, and from the violence and frequency of the cough. 
Here medical treatment is necessary, since it lessens suffering, dimin- 
ishes the violence of some of the symptoms, and so promotes the safety 
of the patient. In infants, under these conditions, we order five drops 
of sweet spirit of nitre, two or three of syruj) of ipecacuanha, and two 
of paregoric, in a teaspoonful of sweetened water every two hours, at 
the age of six months. At one and two years, we double the propor- 
tions of the active ingredients. Should even these small doses of ipe- 
cacuanha cause any sickness of stomach, we lay that drug aside. One 
of the best combinations is the following : 

R. — Potass. Citrat., gj. 

Spts. Ether. Nit., fjij. 

Tr. Opii Deodorat., "Ji!-'^ij vel xxiv. 

Syrup. Simp., f^^vj. 

Aquae, f-ij.— M. 

Dose. — A teaspoonful every two or three hours, at five years of age. 



778 MEASLES. 

In younger children, from two to five years, the same formula may 
be used, except that the laudanum should be reduced to six minims. 
When the cough is very dry, scraping, and, as it sometimes is, incessant, 
there should be added to the above mixture syrup of ipecacuanha, in 
the proportion of five to ten drops to every teaspoonful, according to 
the age of the child; and there may and ought to be given from time 
to time, if the patient be not too drowsy from the effects of the fever 
or the mixture, an extra dose of opium. We prefer nearly alwaj'S the 
deodorized laudanum. Of this from two to four drops in a teaspoonful 
of water may be given two or three times a day, or, better still, once 
or twice in the evening, to children over five years of age. From one 
to five years of age, one or two drops are enough. In some few children 
paregoric may answer better, but this rarely happens. When it is 
o'iven, ten to twenty drops at five years, five or ten at one year, and 
from half a teaspoonful to a teaspoonful over five years, may be used 
instead of the laudanum. 

Depletion, except that which comes of the above treatment, is unnec- 
essar3^ We did, in past years, use depletion in 2 cases out of 257 regu- 
lar cases of which we kept notes. In one, a venesection to four ounces 
was used in a boy seven years old, on account of the great violence of 
the febrile movement; and in the second, leeches w^ere applied to the 
temples for an intense headache in a girl nine years old. For many 
3'ears past we have used no general bleeding, but might be tempted to 
use leeches in a case of the same kind as that just mentioned, in which 
the pain in the head was something quite out of the usual waj^. Instead 
.of venesection we should make use of a warm bath continued for fifteen 
to twenty minutes. If the temperature of the body be very high, it 
may be reduced by careful sponging with tepid or cool Avater. 

Sometimes, when the cough is very troublesome, a mustard foot-bath 
used every three or four hours, and a mild liniment, as one composed 
of sweet oil and spirit of hartshorn, or of chloroform, camphor, and 
soap liniment, rubbed gently upon the front of the neck and over the 
upper part of the sternum, will assist materially in palliating this symp- 
tom. 

When the conjunctival inflammation is acute and painful, it may 
be relieved by lotions with simple warm water, milk and water, or 
sassafras-pith mucilage, alone or mixed with rose-water. If the head- 
ache be very violent it can generally be relieved by the use of a laxa- 
tive, by the occasional use of a mustard foot-bath, or of a sinapism to 
the nucha, and by the application of cold to the head. 

If, at any time during the course of the case, symptoms of exhaustion 
appear, the most nourishing and concentrated food, with alcoholic 
stimulants in graduated doses, should be promptly resorted to. 

T\\Q malignant form of the disease must be treated chiefly with stimu- 
lants and tonics. The most useful are wine and brandy, quinia, am- 
monia, capsicum, &c. Camphor and opium would be proper, were the 
case attended with severe nervous s^'mptoms. The diet ought to be 
nutritious and digestible, and may consist of milk and bread, light 
broths, and beef tea or essence of beef 



TREATMENT. 779 

"When local iuflammatioDS occur, thej may be treated by a few dry 
cups, or by means of counter-irritants, of which the most suitable are 
mustard, spirit of turpentine, or ammonia. Blisters ought to be 
avoided, as they are ver}' apt to occasion dangerous and even fatal 
sloughing. 

Treatment of the Complications. — Bronchitis, Pneumonia. — The 
mode of treatment of these complications must depend upon the stage 
at which they are developed, and upon the age and constitution of the 
subject. When they occur during the first stage, one of the most im- 
portant points in the treatment is to endeavor to favor the appearance 
of the eruption, and when in the second stage, and the eruption hasre- 
troceded wholly or in part, the same indication applies with equal force. 
When they appear during the third stage, they are to be treated with- 
out any regard to the eruption, but always with reference to the fact 
that the patient has just passed through an acute febrile disease, which 
must have weakened in some degree the vital powers. 

It may be stated in general terms, that the treatment proper for 
these local inflammations when they occur as primary affections, is 
proper also, with some reservations, under the circumstances we are 
now considering. 

Thus even local depletion should be employed only with the greatest 
care, and, indeed, we should recommend in preference the application 
of dry cups, or of sinapisms. 

Purgatives should also be used with caution, on account of the dispo- 
sition to gastro-intestinal irritation which is always present in this dis- 
ease. Our own practice is to employ moderate counter-irritation, in 
conjunction with minute doses of sulphurated antimony and Dover's 
powder, or a mixture containing citrate of potash and syrup of ipecac- 
uanha. When in these cases the skin is at all coolish, or bathed with 
too considerable a perspiration, we have found the liquor ammonise ace- 
tatis a very useful remedy. 

It is universally acknowledged that it is exceedingly important to 
assist nature in throwing out the rash, whenever these complications 
either prevent its formation, or cause its retrocession. The true mode 
of doing this is to cure or alleviate the internal inflammation, which is 
the cause of the difficulty. To attain this end the above plan of treat- 
ment ought to be instituted at once. At the same time, we may 
greatly assist the appearance of the eruption by a persevering employ- 
ment of counter-irritants. The best of these is, we believe, mustard, 
and in some cases a warm bath. The mustard maybe used in the form 
of plasters, poultices, or baths. Our own plan in moderately severe 
cases, is to apply a mustard poultice to the interscapular space, and to 
make use of a mustard foot-bath, two or three times a day, while in 
severe and urgent attacks we direct the cataplasm and bath to be re- 
newed every two or three hours, taking care, however, to aj)ply tlie 
former alternately to the front and back of the chest, in order to avoid 
all possibility of too violent an action upon the skin; the feet and limbs 
also ought to be carefully watched, to avoid the same danger. AVe have 
had occasion to observe the great efficacy of this unremitting employ- 



780 MEASLES. 

mcnt of revulsives, in several severe cases of broncbitis in young cbil- 
dren. In some we bave depended solely upon this treatment, and tbe 
use of small doses of ipecacuanha and spiritus Mindereri. In one par- 
ticularly, which occurred in a child eight months old, tbe attack came 
on in the first stage. On the fourth, fifth, and sixth days, tbe dyspnoea 
was excessive, the respiration running up to 70 and 80 -, tbe pulse was 
frequent and small; the skin pale and rather cool; and the irritability 
and restlessness very great. For a period of twenty-four hours, we 
used tbe poultices and foot-baths every two hours regularly, and gave 
internally the spiritus Mindereri at the same intervals. Nothing else 
was done. On tbe sixth day, when one of the poultices was removed 
from the interscapular space, tbe integument beneath was observed to 
be covered with the measly stigmata, whilst there were none as yet on 
any other part of tbe surface. From this time tbe eruption came out 
freely, and tbe child recovered rapidly. 

The warm bath may be used under the same circumstances. It should 
be given with great care, the child being wrapped in a warm blanket 
the moment it is removed from the water, to prevent tbe least sensa- 
tion of chilliness. It may either lie for a short time in tbe blanket, or 
be wiped dry beneath it, and then dressed. 

In some of tbe cases of bronchitis, there has been profuse secretion 
attended with extensive subcrepitant and mucous rales. In such in- 
stances we have found the internal use of the syrup or infusion of poly- 
gala seneka, with an occasional revulsive, very effectual. 

The diarrhoea which occurs so frequently seldom requires any treat- 
ment. Indeed, unless it indicates evident entero-colitis, or is accompa- 
nied by frequent mucous or bloody stools, and by pain and tenesmus, 
it is better not to interfere with it, beyond paying strict attention to 
tbe diet. When attended, however, with tbe symptoms just mentioned, 
it must be treated by astringents, by opium and ipecacuanha, and by 
the application of poultices to tbe abdomen. The seven cases that oc- 
curred to ourselves recovered under tbe use of laudanum enemata, given 
twice or three times a day, tbe strictest diet, and small doses of Dover's 
powder. 

Laryngitis, SiS it occurs in most of the cases, needs but little treatment 
beyond careful avoidance of cold, the use of some mild nauseant, and 
revulsives to tbe neck. It is yovj seldom of a dangerous character. 
When, however, it assumes tbe character of pseudo-membranous croup, 
it must be treated with all activity, in tbe manner described in tbe ar- 
ticle on that disease. In only two of the eight cases we have seen, did 
it appear at all threatening, and both of these recovered under tbe use 
of emetics and moderate leeching of the throat. 

The cerebral symptoms which sometimes occur, must be treated differ- 
ently in different periods of tbe disease. In tbe early stage, when they 
last but a short time and do not recur, they require nothing more than 
a warm bath and tbe use of revulsives. If they continue to recur, or 
are followed by stupor or other cerebral symptoms, more energetic treat- 
ment becomes necessary. If tbe child is strong and hearty we may 
apply dry cups to tbe back of the neck or temples, and resort to purga- 



SMALL-POX. 781 

tives, revulsives, and cold applications to the head. When the symp- 
toms are violent, and when the heat is intense, it has been proposed to 
use cold lotions in the manner recommended in scarlatina. The evi- 
dence upon this point is not very conclusive, and as we have never 
used them^ nor seen them used, nor indeed seen any necessity for a re- 
sort to them, we can offer no opinion in regard to their value. 

We have met with five cases of convulsions in the first stage. One 
occurred in a boy five years old; the convulsions were slight, lasted 
not more than ten or fifteen minutes, and were followed by no bad 
symptoms. The intelligence of the child returned very soon after- 
wards. The only remedy used was a warm bath. The other cases 
have already been described. 

When convulsions occur in the second or third stages, it is very im- 
portant to ascertain whether they are not the result of some local 
disease. Two of the three cases that came under our notice accom- 
panied violent attacks of bronchitis. The third was caused by conges- 
tion of the brain. Here the treatment must be directed against the 
local disease, if that can be detected. When, on the contrary, the con- 
vulsions seem to depend on nervous irritation, they may be treated 
with baths, revulsives, purgatives, and the careful administration of 
opium, as recommended by Sydenham, Copland, Eilliet and Barthez, 
and other authors, or of bromide of potassium, camphor, assafoetida, 
musk, or hyoscyamus. If accompanied by intense heat and great dry- 
ness of the skin, without local complications, cold or tepid lotions may 
also be tried. 

The treatment suitable when any of the complications or sequelse 
become chronic, will be found in the articles devoted to the respective 
diseases. Bearing in mind the tendency to the development of scrofula 
or tuberculosis after this disease, the most careful attention should be 
paid to all hygienic measures; and alteratives and tonics, as syr. ferri 
iodid., cod-liver oil, and quinia, should be administered. 



AETICLE YII. 

VARIOLA, OR SMALL-POX. 

Definition ; Frequency ; Forms. — Yariola is an epidemic and con- 
tagious disease, characterized by an initial fever, lasting from three to 
four days, and followed by an eruption at first papular, then vesicular, 
and afterwards pustular ; the eruption attains maturity in from six to 
nine days, after which the pustules are converted by desiccation into 
scabs, which fall off iTetween the fifteenth and twenty-fifth daj'S. 

ThQ frequency of the disease varies greatly in different years, because 
of its epidemic nature. It is far less common in childhood amongst the 
middle and upper classes of the community, than either measles or 
scarlatina, in consequence^ no doubt, of the attention paid to vaccina- 



782 



SMALL -POX. 



tion. During the earl}^ months of 1865, one of us had the opportunity 
of studying a severe epidemic which occurred in portions of this city, 
and we liave published elsewhere^ an analysis of thirty cases in chil- 
dren under fifteen j^ears of age, observed at that time. Apart from 
these cases, however, we had met with but two cases of the disease 
under fifteen years of age, during the fifteen years preceding 1871- 
72, whilst during the same period we had met with 263 of scarlatina, 
and upwards of 314 of measles. In the last-mentioned j^ears, a severe 
epidemic occurred in this city, when we again saw numerous cases at 
all ages. It prevails to a greater extent amongst the poor and des- 
titute classes, who neglect the attention to vaccination necessary to 
preserve children from the disease. 

We abstract from the article already referred to, the following table, 
showing the entire annual mortality from variola in Philadelphia, to- 
gether with the relative mortality during the early 3- ears of life, for the 
twenty -four years ending 1873. 

MORTALITY FROM VARIOLA. 



1848, 

1849, 
1850, 
1851, 
1852, 
1853, 
1854, 
1855, 
1856, 
1857, 
1858, 
1859, 
1860, 
1861, 
1862, 
]863, 
1864, 
1865, 
1866, 
1867, 
1868, 
1869, 
1870, 
1871, 
1872, 



Under 


Between 1 


Between 2 


Total of all 


1 year. 


and 2 years. 


and 5 years. 


ages. 


21 


13 


17 


100 


25 


20 


34 


152 


13 


8 


4 


40 


40 


30 


54 


216 


89 


54 


100 


427 


22 


9 


9 


57 


12 


4 


6 


49 


57 


39 


85 


275 


86 


44 


88 


390 


19 


17 


11 


65 


1 


2 


1 


7 








1 


2 


14 


10 


16 


57 


159 


105 


200 


758 


52 


44 


66 


264 


33 


24 


28 


171 


57 


31 


61 


260 


104 


50 


112 


524 


32 


17 


27 


144 


16 


4 


11 


48 











1 


1 


3 





6 


3 





3 


9 


203 


112 


292 


1879 


347 


188 


446 


2585 



Total, 



1406 



828 



1672 



8486 



An inspection of this undoubtedly establishes the fact that whenever 
the contagious principle of variola, favored by some peculiar epidemic 



1 Amer. Jour, of Med. Sci., October, 1869, p. 322. 



CAUSES — SYMPTOMS. 783 

influence, is introduced into this community, it finds a large number of 
unprotected subjects who fall ready victims to its attack. 

We shall, in our description of variola, refer to several forms which 
it may assume. These are merely degrees of severity of the same dis- 
ease — types given to each case by several causes. Chief amongst these 
is the presence or absence in the person attacked, of the protective 
power of the vaccine disease. IN'ext is the type of the epidemic prevail- 
ing at the time, and last we must place the inexplicable and utterly 
uncertain influence of individual constitution. According to the degree 
of reaction of the variolous poison in the system of the patient, shall we 
have distinct or discrete, confiuent or hemorrhagic small-pox; or that form 
modified by vaccination, inoculation, or previous natural small-pox, 
called varioloid. 

AYe shall also describe the complications of the disease. 

Causes. — The principal causes of variola are contagion and epidemic 
influence. 

It is not clearly ascertained at what period of its course the disease 
first acquires the property of infectiousness. Some assert that it is not 
until after suppuration is established. This is, however, to say the 
least, doubtful, and it is best, therefore, to take any precaution that 
may be necessary to prevent the extension of the disease, from the 
moment that its real nature becomes apparent. There can be no doubt 
that the hodij may still impart the disease after death, and that clothes 
worn by the patient retain the contagious principle, unless freely ex- 
posed to the air, for days, months, and, it is said, even for years. It is 
also capable of infecting furniture or letters, and may thus propagate 
the disease at any distance, and for an indefinite period, by fomites. 

One attack protects the constitution, in the great majority of cases, 
against subsequent contagion. When persons who have once had the 
disease contract it again, it almost always assumes a much milder and 
less dangerous form. 

In the report of the Municipal Hospital of Philadelphia, made to the 
Board of Health of Philadelphia, for the year 1872, Dr. Wm. M.Welch, 
the physician in charge, states that out of the whole number of cases 
(2377) of variola admitted during the violent epidemic of 1871-2, 15 
were said to have had a previous attack of the disease. Of these 15 
cases, those Avhich could not show a single scar as the result, he should 
classify as of doubtful authenticity; those which exhibited only a few 
scars, as of probable authenticity; and those which exhibited well- 
marked pitting, as authentic. To the first class belonged 7 cases, of 
w^hich 3 died ; to the second class belonged 3 cases, all of which recov- 
ered ; to the third class belonged 5 cases, all of which recovered, and in 
all of which the eruption was very light, so much so in one as to be 
characterized as doubtful. 

The period of incubation, or the time elapsing between the reception 
of the poison and the onset of the malady, varies generally between 
nine and twelve days. It may, however, be seven or fifteen days. 

Symptoms; Course; Duration. — We shall describe thi-ee stages of 



784 SMALL-POX. 

the disease: 1. That of the initial or eruptive fever; 2. That of the 
progress and maturation of the eruption; and, 3. That of decline or 
desiccation. In addition to these, some writers make another stage, 
that of incubation, which includes the period between the introduction 
of the poison into the system, and the appearance of the first symp- 
toms. This stage is seldom marked by symptoms suflSciently charac- 
teristic to enable us to detect the approaching disease, and in many 
instances is probably entirely unnoticed by the patient. 

The first stage, or that of initial fever, commences generall}^ in chil- 
dren with pains in the bones and loins, and sometimes with rigors or 
chilliness, accompanied with headache, and soon followed by fever. 
Nausea and vomiting often exist from the first, or come on soon after 
the appearance of fever and headache. At the same time there is loss 
of appetite, thirst, and more or less obstinate constipation. The tongue 
is red at the point and edges. One of the characteristic symptoms of 
this stage is pain in the loins, which generally dates from the first or 
second day, and which, though varying much in degree, is usually 
severe. The patients often complain also of abdominal pains, which 
seem to be colicky, and are referred either to the epigastric or umbili- 
cal region. 

Fever and headache are the most constant of all the initial symp- 
toms. The chilliness and rigors which frequently exist in adults are 
not easily ascertained in the cases of children, and are therefore much 
less important. The fever varies greatly as to degree ; the heat of skin 
is generally considerable, the temperature rising to 104° or 10e5°, and 
may be accompanied either with dryness or moisture. The pulse is 
commonly full and frequent, rising to 120, 140, or 160 beats, according 
to the severity of the case and the age of the child. The headache is 
usually frontal and often very severe. In some cases there are strongly 
marked cerebral s^-mptoms, consisting of excessive restlessness and irri- 
tability, insomnia or somnolence, delirium, and even convulsions. 

The various symptoms just enumerated continue up to the moment 
when the eruption begins to make its appearance, which happens gen- 
erally in the course of the third day, though it may occur as early as 
the second, or as late as the fifth, sixth, or even seventh. In severe 
and confluent attacks, the eruption, as a general rule, begins earlier 
than in mild and discrete cases. 

Second Stage, or that of JEriiptmi. — In the great majority of cases, the 
specific eruption makes its appearance in the course of the third day 
from the beginning of the fever. This is the law of the disease. Be- 
fore, however, describing it, we must state that not rarely a more or 
less extensive roseolous rash precedes the specific eruption. So well 
known is this that it has been called roseola variolosa. It looks so like 
measles as to make a correct diagnosis difiicult, since nothing could 
reveal its true character unless it were known that the subject had 
been exposed to variolous infection, in which event the unusual severity 
of the constitutional phenomena, compared with those generally at- 
tendant upon roseola, might well lead the practitioner to defer his 



SYMPTOMS. 785 

opinion. This roseola occurs in all forms of small-pox. Dr. Welch 
thinks he has seen it most frequently and in greatest quantity in cases 
of mild varioloid. 

The specific eruption appears, then, on the third day^ in the form of 
small, isolated, and rounded red specks, which soon become projecting 
and solid, or in other words are converted into papules. The papules 
are from a third to two-tliirds of a line in diameter, of a more or less 
vivid red color, which disappears under pressure, to return immediately 
when the pressure is removed. Thej^ are also hard, and feel almost 
like shot imbedded in the derm. The eruption shows itself first on the 
face, and generally about the chin and mouth, and then extends to the 
rest of the face, to the neck, trunk, limbs, feet, and hands. It some- 
times happens, particularly in very young children, that the eruption 
appears first about the genital organs, whilst in other cases it is first 
observed on the lower part of the loins, or upon the thighs. The pap- 
ules increase gradually in size and prominence for one, two, or three 
days, and, as a general rule, some time in the course of the second 
day of the eruption, begin to change into vesicles. This change takes 
place by the formation on the top of each papule of a little transparent 
elevation of the cuticle, beneath which is deposited a drop of serosity. 
The conversion of the papules into vesicles occurs first on the face, and 
then on the neck, trunk, and extremities. The vesicles are at first 
smaller than the papules, and acuminated in shape, but as they grow 
larger, become gradually flattened and depressed in the centre; after a 
time they cover the whole papule, and before long exceed it in size. 
As these changes take place, the fluid they contain loses its transpar- 
ency, becomes opaline, and by degrees the vesicles are transformed 
into pustules, and thus the third stage of the eruption or that of suppu- 
ration begins. 

The 2:)ocks are more or less numerous, according to the extent and 
severity of the eruption. When scattered over the surface so as not to 
touch at their edges, the disease is said to be distinct or discrete; when, 
on the contrary, so numerous as to come into contact and run together, 
it is called confluent. Of these two varieties, the latter is necessarily 
more severe and dangerous than the former, in consequence of the 
greater extent of tegumentar}^ surface inflamed. During the various 
changes the vesicles undergo, they are surrounded by small, inflamed 
areolae, which diff'er in appearance according to the number of the ves- 
icles. In cases of the discrete form, in which the eruption is sparse, 
so that the pocks are widely separated, the areolae fade gradually into 
the natural color of the skin, at the distance of a third or two-thirds of 
a line or more from the base of the vesicles, whilst in those in which 
the eruption is more abundant, they run together, so that the spaces 
between the pocks are of a more or less bright-red color. In confluent 
attacks, again, the areolae are more or less imperfect, according to the 
manner in which the vesicles are grouped together. 

The change of the vesicles into pustules takes place generally from 
the fourth to the sixth day of the eruption. During this process the 

50 



786 SMALL-POX. 

fluid of the pocks becomes more and more opaque, whitish, and at length 
assumes a yellowish color, being in fact converted from serum into pus. 
At the same time the pocks become larger, begin to distend, and, as 
they approach complete maturation, gradually lose their umbilicated 
shape and become convex on the surface. The formation of the pustules 
follows the same course as did the vesicles, beginning on the face and 
extending thence to the neck, trunk, and extremities. The areolae that 
have just been described as existing during the vesicular stage of the 
disease, continue during the earlj^ part of the stage of pustulation, but 
decline towards its termination, assuming as they disappear a purple 
tint. The number of pustules is in j^roportion, of course, to that of the 
vesicles, but from the increase in size of the pocks during the changes 
from papules into vesicles and pustules, the eruption, when at its height, 
seems to be greatly more extensive than would have seemed probable 
at the beginning of the first stage. As a general rule the pocks are 
most numerous on the face, and after that j^art on the neck and limbs. 
On the trunk the eruption is always much less abundant than on other 
parts of the body, and even when confluent in the highest degree on 
the face and neck, it is generally so only in patches on the limbs, while 
it is discrete on the thorax and abdomen. 

Simultaneously with the eruption upon the skin, there occurs one also 
upon the mucous membranes, particularly those of the mouth, nasal 
passages, fauces, eyelids, and sometimes of the prepuce and vulva. It 
begins with more or less vivid redness of the membrane, which is fol- 
lowed by the production of little elevations, the real nature of which, 
whether papular or vesicular, seems not to be clearly determined. 
About the second or third day these red elevations assume the appear- 
ance of small, whitish, rounded, and umbilicated pseudo-membranous 
points, which last generally about five days, and are then detached, 
leaving usually a little ulceration or erosion, which heals without leav- 
ing a cicatrix. 

A short time after the appearance of the pustules in the mouth and 
throat, a true inflammation of the mucous membrane of those parts takes 
place. When the gums are inflamed they become swelled, red, and 
spongy, and are dotted over with white pseudo-membranous points of 
a rounded shape. Sometimes the velum pendulum, and more rarely 
the tongue, present the same white points, with redness and injection 
of the membrane between. In most of the cases there is also partial or 
general inflammation of the pharynx, which occurs subsequently to the 
formation of the variolous pustules. The existence of this inflammation 
is denoted by more or less severe sore throat, attended with difficulty 
of swallowing, and with swelling and tenderness of the submaxillary 
glands. When the mucous eruption extends to the larynx, as often 
happens, there is pain in that part; the voice becomes hoarse or whisper- 
ing, and there is a hoarse, laryngeal, smothered cough. The pharyngo- 
laryngitis just described occurs generally between the third and sixth 
days of the eruption, and ceases about the eighth or thirteenth. In 
some instances it does not exist at all or only to a slight extent. 



SYMPTOMS. 787 

During the eruption there is more or less inflammation and swelling 
of the subcutaneous cellular tissue, the degree of which depends on the 
extent of the eruption. The skin becomes tense, red, shining, and 
elastic under the finger, and more or less hot and painful. The swelling 
is greatest upon the face, where it commences about the fourth or fifth 
day of the eruption, and goes on increasing for five or six days, occa- 
sioning much pain, stiff*ness, and inconvenience to the child. The swell- 
ing diminishes when desiccation begins, and ceases entirely as the 
latter is accomplished. 

It is important to study carefully the general symptoms of the second 
stao-e. The fever which existed during the initial stao-e sometimes con- 
tinues during the first day or two of the eruption. When, however, 
the papules are fully thrown out, the fever subsides or disappears en- 
tirely, so that the pulse falls from 100,, 120, or 140 beats, to 100, 80, 76, 
or 74, and the heat of skin diminishes at the same time. The child 
remains without fever usually throughout the vesicular period of the 
eruption, that is to say, until the fourth, fifth, or sixth day; during 
which time the appetite sometimes returns, sleep is tranquil and quiet, 
and the patient is in most respects well and comfortable. 

About the fifth or sixth day of the eruption, at which time the matura- 
tion of the pustules is nearly completed on the face, and that process is 
commencing on the extremities, a new fever, to which the technical 
term secondary fever is applied, makes its appearance. The pulse rises 
again to 88, 100, 120, and 140, and becomes strong, hard, and full, w^hilst 
the skin is hot and dry. After continuing for some days the secondary 
fever diminishes after the suppuration is fully established, and disap- 
pears about the time that desiccation is nearly completed on the face, 
and has commenced upon the limbs. It ceases generally, therefore, 
about the ninth or eleventh day, having lasted between four and six 
days. This attack of fever is-evidently the consequence of the suppu- 
rative stage of the disease, or of the conversion of the vesicles into 
pustules. 

Towards the termination of the second stage, at the very height of 
the disease, w^hen the pustules begin to break and discharge their con- 
tents, the patient exhales a peculiar, disagreeable, and fetid odor, which 
is characteristic of the disease. 

The third or declining stage is that of the desiccation or drying of the 
pustules, and their desquamation. The desiccation commences generally 
between the sixth and ninth days, and terminates between the tenth 
and fourteenth. The formation of the crusts begins upon the face and 
extends thence to the neck and limbs. It does not reach the limbs 
usually until about two or four days after it has commenced on the 
face. The mode in which the drying of the pustules takes place is not 
the same in all. In some a dark point is formed in the centre ^vhich 
gradually extends and converts the whole pustule into a hard crust; in 
others the whole surface dries at the same time; w^hile in others again, 
the epidermis gives way and allows the contained fluid to escape, which 
then hardens into yellowish, irregular crusts, Avhich become brown 



788 SMALL -POX. 

before they fall off. Some of the pustules, particularly those upon the 
arms and le^rs, do not form scabs at all, but shrink away from the ab- 
sorption of their fluid, leaving behind nothing but pellicles of cuticle, 
which fall off by desquamation. 

The desquamation or falling of the crusts begins from the eleventh 
to the sixteenth, and ends somewhere between the nineteenth, twenty- 
fifth, and even fortieth days of the eruption. When the scabs fall off, 
the appearances presented by the skin beneath vary in different cases. 
In some a true ulceration and loss of substance of the derm has taken 
place, which gives all the characters of a suppurating ulcer when des- 
quamation has begun early in the disease ; when that process occurs at 
a later period, the ulcer is found to be dry and cicatrized. In both 
these forms of desquamation, the cicatrices form little pits or depres- 
sions, which remain during life. In other instances, the fall of the 
scabs leaves red and excoriated surfaces which are on a level with the 
surrounding skin, but which soon dry, leaving blotches of a reddish- 
brown color, that do not disappear entirely for months. No cicatrices 
remain when desquamation takes j^lace in this manner. In a third 
series of cases the crusts do not fall until the surface beneath has com- 
pletely cicatrized, and the only traces left behind are more or less deeply 
tinted reddish spots, with occasional slight furfuraceous exfoliation of 
the cuticle, all of which disappear entirely after a time without leaving 
pits or cicatrices. 

To conclude the account of the symptoms of the disease, we have a 
few words to say in regard to the condition of some of the important 
oi'gans throughout the course of the malady. 

The tongue presents no appearances peculiar to the disease, other 
than the eruption already described. It is generally moist, more or 
less furred, and either pale or red in color. The ahdow,en usually 
remains soft aikd undistended, though in* some instances it is slightly 
tumid and hard, with occasional pains in the epigastric, umbilical, or 
iliac regions; in simple cases, the latter symptoms rarely last more 
than a short time, and when otherwise they are almost always the sign 
of some complication. The constipation which exists during the initia- 
tory stage generally continues throughout the disease, though in some 
instances a slight diarrhoea occurs about the end of the first or second 
week, after which the bowels regain their natural condition. If severe 
diarrhoea should make its appearance, it is almost alwaj'S the sign of a 
dangerous complication. The nausea and vomiting which are so often 
present during the initial stage, cease after the appearance of the erup- 
tion, and recur only in rare cases, or in consequence of some complica- 
tion. The appetite is almost always lost during the course of the dis- 
ease, though it sometimes returns in the period between the termination 
of the initial and the commencement of the secondary fever; thirst is 
acute as a general rule, and more or less so according to the violence 
of the fever. 

The urine presents, during the course of the disease, the ordinary 
febrile characters of lessened quantity and heightened color. The 



SYMPTOMS. 789 

urea, uric acid, and pigment are increased, and the chlorides much 
diminished. Albuminuria is occasionally present at the height of the 
disease ; it is, however, temporary, and apparently not of very grave 
import. Casts of the renal tubules are also present in some cases. 
The frequency with which this condition exists probably varies in differ- 
ent epidemics, since we have detected it but rarely in our cases, while 
Parkes states that it is present in about 30 per cent, of all cases. After 
the subsidence of the secondary fever, the urine frequently becomes 
very abundant, of pale color, and of low sp. gr. Thus, in one of our 
cases, in a girl aged 18 years, the daily amount of urine passed from 
the tenth to the thirteenth day of the eruption was f^clx, or ten pints, 
of sp. gr. 1001, as clear as spring-water, containing no albumen, but 
with a fair j^roportion of chlorides. In another case, in a young man 
aged 20 years, the patient also passed, on the eighteenth day, i^clx of 
crystal-clear urine, of sp. gr. 1007, without albumen but containing 
abundant chlorides. In a third case, in a boy aged 13 years, the amount, 
on the twelfth day of the eruption, was f^xlv. 

The strength of tlie child is not, as a general rule, greatly diminished, 
except' in severe and dangerous cases. Restlessness, irritability, crying, 
and delirium, which are of such frequent occurrence in the febrile dis- 
eases of children, are not usually very strongly marked in regular cases 
of variola. They exist, but it is to a moderate extent only. 

We pass on now to the confluent forms of the disease. 

It is not possible to predict from the character of the initial fever 
what is to be the type of eruption which is to follow, since in discrete 
variola, and even in varioloid, the precursory fever and other symp- 
toms, often run alarmingly high, while, on the other hand, a case des- 
tined to be confluent, or even hemorrhagic, does not always exhibit 
violent phenomena at the outset. As the time for the eruption ap- 
proaches in confluent cases, the skin usually gives evidences of active 
inflammation of its deeper structures. It becomes thickened, swollen, 
hard, dark in tint, and as the eruption advances, the countless number 
of papules and vesicles, which cover all parts of the body, increase the 
violence of this inflammatory action, and give rise to an earlier appear- 
ance of the secondary fever, which is marked by higher temperature, 
more active delirium, and greater disturbance of the circulation than 
in discrete or moderate small-pox. As the vesicles form upon the pap- 
ules, they so crowd the surface that their edges run together, thus 
making the confluence, and no portions of natural skin remain on which 
to form the areolae, which therefore are absent. As the pustules follow 
the vesicles they do not develop well, but remain flattish and slug- 
gish, with a whitish, ill-concocted pus on some parts of the body, par- 
ticularly the face and backs of the hands. They run together into 
large flat blebs or bullae, of several inches or more in extent. Some- 
times portions of the loosened cuticle are rubbed off by the movements 
in bed, or by scratching. The parts thus denuded look raw, and exudo 
a sanious fluid. 

In severe confluent cases the eruption extends to the mucous mem- 



790 SMALL -POX. 

brane of the nose, mouth, fauces, ej^elids, and perhaps to the prepuce 
or valva, as in the distinct form, but with very different severit}^ and 
consequences. The inflammation produced b}^ the eruption causes en- 
larirement of the tongue^ swelling of the ftiuces, pain, and often great 
difficulty of swallowing. The rawness and soreness of the passages, 
and an abundant and usually dark-colored viscid secretion, which 
clogs and clings to the parts, cause great distress, and add to the ex- 
haustion of the patient. At the same time the laryngeal catarrh 
causes cough, hoarseness, partial or total loss of voice, and difficult}^ of 
breathing. Thus, as in violent anginose scarlet fever, and in some 
cases of diphtheria, the supply of air to the lungs is so diminished by 
the various causes of obstruction (swelling, collections of viscid phlegm, 
and spasm of the glottis) that the blood does not receive its due amount 
of oxygen, a venous stasis is established, the skin becomes dark-brown 
or purplish from capillary stagnation, and the patient dies, sometimes 
in great distress, though at others with very little apparent suffering, 
in a state of asphyxia and exhaustion. 

In some cases the heart presents evidences of disease ; the sounds 
become feeble and obscure, the impulse weak, and the action of the 
heart irregular and intermittent. These symptoms, to which special 
attention has been called by Desnos and Huchard,^ are dependent upon 
grave inflammatory changes, either in the endo- or pericardium, or fre- 
quently in the muscular tissue of the heart. In cases where this latter 
lesion is present they have occasionally observed a want of agreement 
in frequency between the contractions of the heart and the radial pulse; 
and also, but as a much more constant sign, a murmur at the apex of 
the heart, soft, deep, diffuse, and inconstant, which differs in its char- 
acter from the murmur which attends endocarditis of the valves. Un- 
doubtedly in many cases of variola where death occurs suddenly, with 
signs of failure of cardiac power and pulmonary engorgement, the ffital 
event will be found to depend on the development of one of these 
cardiac lesions, and especially of myocarditis. 

There is a form of confluent small-pox called superficial confluent, in 
which, though the eruption is really confluent, it runs through the 
stages of maturation, desiccation, and desquamation so rapidly that 
the constitution is not greatly tried, and the patient recovers without 
difiiculty. 

Even in the severe form, the patient maj^, if his constitution be good, 
pass safely through the disease. 

The hemorrhagic, malignant, or petechia! form is happily rare. We 
had rarely seen it until the epidemic of 1871-72 showed it to us in all 
its terrible power. Our forefathers knew all about it. We, of the 
generation which has risen since the introduction of vaccination, had 
read of it, but took little heed of what the variolous poison might do 
when it exerted its malignant forces. In this form the patient is weak 
and feeble from the beginning. The surface assumes a singular reddish 



1 Des complications cardiaques dans la variole, Paris, 1871. 



VARIOLOID, OR MODIFIED SMALL-POX. 791 

hue as the eruptioD comes out. The vesicles when they form upon the 
papules, instead of filling with lymph, and then pr.s, contain only a 
thin, sanguinolent liquid; they mature very imperfectly, or rather not 
at all, not acuminating hut remaining flattish, or irregular in shape, 
and flabby. While the eruption is struggling along in this irregular 
mode, the vessels of the cutaneous tissues become gorged and partially 
stagnant, so as to give to the surface dark red, brown, blue or purplish, 
and livid tints. Extravasations take place amongst and beneath the 
eruptive points, the cuticle forming the bloody pocks breaks, blood 
exudes, and forms dark scabs, and the patient is so changed from his 
natural aspect that we may comprehend how in the olden time, people 
who had not the consolation which vaccination gives, may have been 
driven from the bed and even from the house of the sufferer in hope- 
less terror. Such cases look no longer human. The swollen face, 
purple or black, the dark or crimson-red eyeball, wnth the whitish 
cornea sunken into a pit formed by the projection of the blood-colored 
and oedematous conjunctival membrane, the eyelids thick and stiff and 
imperfectly closing, the gross bodj'-, changed from all its natural bright 
to blackish tints, the cuticle dissected from the skin by bloody exuda- 
tions, which weep and stain the clothing and bed-linen. Such is the 
variola nigra or black small-pox of the old writers, and well does it de- 
serve its name. 

Yarioloid.or Modified Small-pox — This is a term now usually ap- 
plied to the modified form of the disease, as it occurs in individuals who 
have been vaccinated, or who have already had the natural or inocu- 
lated disease. 

Dr. Welch's rule is a very good one, — "to classify as variola all un- 
vaecinated cases, no matter how mild, all malignant cases, and all the 
vaccinated cases in which the eruption does not reach maturity until 
after the sixth or seventh day from its first appearance." The true 
point of distinction here, when any uncertainty as to vaccination exists 
(and this is not rare amongst the poor), is the time of maturation of 
the eruption. This, in varioloid, ought to be matured and in the decline 
by the sixth or seventh day. 

The initial symptoms of varioloid are of the same general kind as those 
of natural small-pox, differing merely in degree. But the physician 
ought to know that, in a few cases of even very mild varioloid, while 
the eruption is destined to be sparse, to consist of but few pocks, and 
to run through its stages in five or six days, the initial fever may be 
very highland the attendant phenomena of pain, nervous disturbances, 
loss of strength, &c., very marked. We once saw a girl nine years old, 
who was ill for three days with very high temperature, delirium, stupor, 
prostration of strength, violent headache, and rapid pulse, so that her 
case looked very threatening, and left the diagnosis in great doubt. On 
the third day.a moderately abundant variolous eruption came out, when 
all the unpleasant symptoms rapidly abated and disappeared. The 
eruption ran through its stages in six days, and the patient recovered 
without a pit. She had been well and carefully vaccinated in infancy. 



792 SMALL -POX. 

These severe initial symptoms are rare, however, in children as com- 
pared with adults. Usually the attack begins with slight fever, head- 
ache, languor, and sometimes constipation, which are followed in two 
or three days, by the eruption. The vomiting, lumbar pains^ and dif- 
ferent nervous symptoms w^iich exist in regular variola, are not often 
present, or, if so, in a very slight degree. The eruption consists of 
papules like those of true small-pox, but usually they are few in number, 
and entirely discrete in their arrangement. The initial fever and other 
symptoms subside completely upon the appearance of the eruj^tion, and 
the child often seems perfectly well. 

The progress and character of the eruption are very similar to those 
of the regular form of the disease, with the exception that the changes 
are more rapidly effected, and, as a consequence, the duration of the 
attack is rendered by so much the shorter. The papules are converted 
into vesicles at a much earlier period — as early as the first or second 
day. The vesicles soon assume a whitish, opaline appearance, become 
umbilicated, and in the course of the second or third day begin to change 
into pustules. The suppurative stage of the eruption, or maturation, 
is seldom accompanied by any marked secondary fever, as in the regular 
disease. When the fever does occur, it is generally very moderate, 
consisting merely in slight acceleration of the pulse and a little in- 
creased heat of skin, and in one or two days it disappears entirely. 
The pustules do not fill usually so well as in regular variola, and not 
unfrequently their contents are rather sero-purulent, than purulent, in 
the proper sense of the terra. The third stage occurs earlier and goes 
through its periods more rapidly than in true small-pox- desiccation 
soon takes place, is speedily finished, and the falling of the scabs, which 
begins as early as the eighth day of the eruption, is usually completed 
about the twelfth or fourteenth. After desquamation is completed, the 
only traces of the disease left are reddish spots or blotches, which dis- 
appear after a time without leaving cicatrices. The whole duration of 
the attack is generally from ten to twenty days. 

Varioloid may be so mild that the patient never goes to bed. Some 
malaise, a little loss of appetite, the appearance on the skin of half a 
dozen papules, which soon become umbilicated vesicles, and then rapidly 
form scabs, constitute the whole history of some cases. Here it is that 
a correct diagnosis is invaluable to the family. To the patient it is of 
no consequence. He is safe, but he may inoculate any or all of those 
who have not been properly protected. 

Complications. — The most frequent and important complications of 
variola in children, are inflammations of the mucous membrane of the 
lower half of the intestinal tube, ophthalmia, otitis, and different hemor- 
rhages. In a smaller number of cases, attacks of bronchitis, pneumonia, 
anasarca, articular inflammations, subcutaneous abscesses, simple and 
pseudo-membranous coryza, angina, and larjnigitis, and o-ther eruptive 
diseases, occur at different periods of the malady. 

It is impossible for us, for want of space, to attempt a description of 
the various symptoms of the different comj^lications just enumerated. 



ANATOMICAL LESIONS. 793 

Having mentioned the possibility and probability of their occurrence, 
we must leave the reader with the advice always to suspect the exist- 
ence or approach of some one of them, when the symptoms, in any case, 
differ much from those which have been described as characteristic of 
the regular form. 

Anatomical Lesions. — The characteristic lesions of smalbpox are a 
certain deteriorated state of the blood, congestion of the internal or- 
gans, and the inflammation of the skin and mucous membranes consti- 
tuting the eruption. The blood is found to be entirely liquid and un- 
coagulable, and of a dark color; or if coagula exist, they are small, soft 
and very dark in color. The exceptions to this rule are those in which 
some acute and severe inflammation exists, under which circumstances 
the dissolved state of the blood is less marked, and fully formed co- 
agula are more abundant. The congestion referred to affects almost the 
whole system. The muscles are firm and of a deep red color; the mem- 
branes of the brain are strongly injected, the sinuses are filled with 
blood, and the cerebral substance presents numerous red points or dots. 
The vessels of the lungs contain a large quantity of blood, and the liver, 
spleen, and kidneys, are all deeply congested. 

The condition of the mucous membranes is important. The pharynx, 
larynx, and trachea, present an eruption, or simple inflammation with- 
out eruption. The eruption exists under the aspect of small, circular, 
thin, and whitish pseudo-membranous points, scattered over the mu- 
cous tissue, and slightly adherent to it, beneath which that tissue is 
often obsei'ved to be red and inflamed. At a more advanced degree, 
and in severer cases, the false membranes have disappeared, and in their 
places we find circular ulcerations, which are either superficial, or they 
penetrate the tissue of the mucous coat and rest upon the muscular, or 
even pierce that and reach to the cartilaginous tissue beneath. In ad- 
dition to these lesions are found inflammation of the mucous tissue 
with its consequences, redness, softening, thickening, and extensive 
deposits of false membrane, quite distinct from the appearances above 
described as characteristic of the eruption upon these tissues. 

It has been a contested point whether a true vesicular or pustular 
eruption ever exists upon the mucous lining of the stomach and intes- 
tines. The general opinion appears now to be, however, that the 
chancres observed in these organs cannot be ascribed to the formation 
either of vesicles or pustules. The appearances that have led some ob- 
servers to consider them as the result of a proper eruption, are the fol- 
lowing. The follicles at the commencement and termination of the 
small intestines, and in rarer cases, of the large intestine also, present 
an abnormal degree of development, appearing in the form of small 
hemispherical or pointed, and sometimes flattened projections, on which 
there often exists a dark, and sometimes depressed central point. At 
the same time Peyer's glands are often enlarged, more projecting than 
usual, softened, and red. 

According to the valuable researches of Desnos and Iluchard {^loc. 
cit.), the heart and pericardium present marked lesions in a considerable 



794 SMALL-POX. 

proportion of cases of confluent variola. These changes were rare in 
cases of the discrete form, and were not detected in any case of varioloid. 
The lesions may consist solely of endocarditis, or pericarditis, or these 
may be associated. These inflammations present the ordinary morbid 
products, and are not attended with the development of pustules. In 
other cases, the muscular walls of the heart are affected with an acute 
myocarditis, which is marked at first by a granular state of the mus- 
cular fibres, which soon passes into fatty degeneration. 

The anatomy of the variolous pock is important and interesting. When 
a vesicle is opened soon after its formation, it is found to contain 
nothing but a little serosity which is perfectly limpid and alkaline, 
while the skin beneath is red, softened, and moist. The umbilicated 
character depends on a filiform adhesion between the centre of the pock 
and the surface of the skin beneath. This adhesion is broken, when, 
at a later period, the pustule becomes globose in shape. The vesicle is 
also subdivided into several chambers by delicate radiating partitions, 
so that a single puncture will not discharge the entire contents. About 
the period of the conversion of the vesicles into pustules, or very soon 
after the formation of the latter, the cavity of the pock will be found to 
contain a false membrane, which is of an opaque white color, soft and 
friable in its texture, and seated upon the derm in small isolated points. 
After a time these points enlarge, and meeting, unite, and form a soft 
pseudo-membranous disk, uneven upon its surface, and which either 
fills the pock completely, or is covered at first with serosity and after- 
wards with pus. This false membrane is secreted originally by the 
true skin. At a somewhat later period it forms an adhesion to the 
inner surface of the cuticle, while still later in the progress of the 
pock, it becomes detached from the cuticle, and remains loose and free 
in the cavity of the pustule, surrounded by the fluid contents of the 
latter. 

Diagnosis. — The diagnosis of this disease in all its forms ought to be 
made as early as possible, in order that the persons in contact with the 
patient, whether from necessity or by accident, may be vaccinated or 
revaccinated. It is well known that exposure to the mildest varioloid 
may produce in the unprotected any form of small-pox, from discrete 
to malignant, according to the constitution of the subject and the tj^pe 
of epidemic prevailing. Therefore the only safety after exposure is in 
the vaccine disease, and, therefore, the lives of the exposed hang upon 
the knowledge and action of the physician in charge, a responsibility 
from which he cannot escape either in the estimate of the public or in 
his own consciousness. 

Dr. Welch concludes from his observations that "vaccination per- 
formed at a period less than seven days previous to the appearance of 
the eruption (small-pox) will not modify the disease," but that when 
performed -'seven days previous, (it) will almost always modify the 
disease to the extent of rendering it harmless." 

Dr. Masson (article on Small-pox, in Eeynolds's System of Medicine, 
vol. i, p. 477) says that to be eff'ective vaccination should have gone on to 



^ DIAGNOSIS. 795 

the stage of areola before there is any illness from small-pox. "It has 
before been stated that when small-pox has been taken into the system 
there is twelve days' freedom from illness, generally, forty-eight hours' 
illness, and then the disease begins to appear on the skin. The areola 
of vaccination is not foll}^ formed until the ninth or tenth da}' of the 
progress of the vaccine vesicles on those who have never been vacci- 
nated before, so that unless there has been time for the areola to be 
formed after the vaccination, before the illness produced by small-pox 
begins, the vaccination will not be of the least benefit." He gives an 
example: "Suppose an unvaccinated person to inhale the germ of a 
variola on a Monday ; if he be vaccinated as late as the following Wed- 
nesday, the vaccination will be in time to prevent the small-pox being 
developed; if it be put off until Thursday, the small-pox will appear, 
but will be modified; if the vaccination be delayed until Friday, it will 
be of no use, it will not have had time to reach the stage of areola, the 
index of safety, before the illness of small-pox begins. This we have 
seen over and over again, and know it to be the exact state of the 
question. Eevaccination will have effect two days later than vaccina- 
tion will have that is performed for the first time, because revaccinated 
cases reach the stage of areola two or three days sooner than in those 
persons vaccinated for the first time." 

It is plain, therefore, that the diagnosis ought to be made as early as 
possible. Can it be made in the initial stage? Not, we think, with 
any certainty. Except in a time of general epidemic prevalence, cases 
of small-pox are almost unknown, and varioloid is very rare, amongst 
children, and the medical man thinks of anything but varioloid or small- 
pox to explain a fever attended with vomiting, anorexia, restlessness, 
or drowsiness in the infant, and the same symptoms with headache and 
general soreness in the older child. The initial fever has no character- 
istic phenomena. When the disease is epidemic, the initial fever, as it 
has been described, may arouse suspicion, and the attendant physician 
may dare to announce the probable approach of the dreaded disease, 
and examine all the exposed persons as to their being fully protected. 
But this course is justified only by the presence of the epidemic. Not 
until the eruption begins to appear can the diagnosis be made with 
certainty; and however easy it may be for old and experienced phy- 
sicians to make it then, we desire to caution the younger and more in- 
experienced as to the possibility of mistake. 

The important points to bear in mind are the following : 1. The pro- 
dromic stage, whether of mere ailing and lassitude, such as may not 
send the patient to bed, or violent fever with nervous symptoms and the 
different signs which declare a severe disease, which lasts two daj'S, and 
on the third of which, as the law, the eruption makes its appearance. 
2. The eruption appears first on the face and about the upper part of the 
neck, and consists of hard, distinct, shotty papules, seated, in mild cases, 
on a nodosal skin. 3. As the eruption appears, the fever diminishes. 
These three points kcjDt steadily in view will usually prevent any mis- 
take. 



796 SMALL -POX. 

The eruption of measles shows itself on the third day of fever, as in 
small-pox, and occasionally appears in distinct points, which give it a 
suspicious likeness to that disease. But the attendant catarrhal condi- 
tions, the coryza, cough, and conjunctival catarrh, with the fact that 
the fever increases as the eruption comes out, instead of diminishing as 
in variola, ought alone to decide between the two. Moreover, a care- 
ful study of the eruption ought to enable us to decide. In variolous 
disease the papules are small, hard, very distinct one from another; in 
measles the papular character is not well-marked, the stigmata are 
larger, broader, flatter, and much less hard and shotty to the touch, 
and very soon they run together and assume irregularly^ crescentic out- 
lines. By the second day of the disease there is rarely any difficulty. 

Yaricella, which from its name, one would think, ought to resemble 
variola closely, has rarely given us any trouble. The prodromic stage 
of varicella never lasts over a day; it often consists of but a restless 
night, and sometimes the first thing to attract the attention of the 
mother or nurse is the eruption. When the prodromic stage does exist, 
it consists merely of some lassitude or irritability, loss of appetite, and 
slight fever. The eruption shows itself at once upon the face and front 
and back of the body. So much is this the case that we alwa^'s have 
the child undressed in order to get a good view of the body. If, on in- 
Bj^ection. a number, three or four or a dozen, or very many rounded, 
projecting, globose vesicles are to be seen, consisting of a thin and 
transparent layer of the cuticle, filled often to bursting with a limpid 
serum, there ought to be no difficulty in the diagnosis. Such an erup- 
tion, appearing with scarcely a prodrome, or merely a slight ailing of 
twelve or twentj'-four hours, cannot be small-pox or varioloid. 

In very mild varioloid, where the eruption counts three or four or 
half a dozen vesicles, and where the prodromes are very mild, it is not 
always easy to be quite secure in one's opinion, and a careless or inex- 
perienced person might very well fail to detect the true nature of the 
disorder. But even here careful inquiry will generally show that the 
health has been disturbed for two days, at least by altered temper, las- 
situde, lessened appetite, and one or two restless nights. These pro- 
dromes, when followed by a few hard, distinct papules, which become 
on the second day vesicles, and then umbilicated pustules, to dry up on 
the fourth, fifth, or sixth, can be nothing but variolous in their nature. 

Again, in severe cases of small-pox itself, embarrassments sometimes 
occur. We once saw an infant, five weeks old, who had never been 
out of the mother's room, seized in the midst of perfect health, with 
violent fever, vomiting, loathing of the breast, and heavy stupor. On 
the second day of the illness the whole cutaneous surface began to red- 
den ; soon the tint became bright-red, not unlike some scarlet fevers, 
but of a more crimson-red ; the skin was swelled, tight, hard, and, so to 
speak, shining. On the third day innumerable hard and distinct pap- 
ules formed upon this evidently acutely inflamed skin, and on the fol- 
lowing day the child died comatose. The child had not been vacci- 
nated, and there were at the time a few cases of varioloid and small-pox 



PROGNOSIS. 797 

in the city. Even in such cases, however, where a deep roseolous or 
erythematous efflorescence precedes and masks the variolous eruption, 
the violence of the prodroraic symptoms, so unlike the mild phenomena 
which precede ordinary roseola or erythema, and particularly the in- 
tensity of the coloration and the hard and swollen condition of the 
skin^ indicating active inflammator}^ states of its deeper layers, w^ill go 
far to prepare an experienced eye for what is coming. 

Prognosis. — The fatality of small-pox varies greatly in different epi- 
demics. The result is also markedly influenced b}^ age. It is particularly 
fatal in inftints under one year of age. Of the whole number of cases, 
2377, admitted into the ^iunicipal Hospital of this city in 1871-2, there 
were 35 children under one 3'ear of age. Of these 26, or 74.28 per 
cent., died. Between the ages of 1 and 15 year^ there w^ere 291 cases, of 
which 95, or 32.64 per cent., died. The mortality was therefore nearly 
three-fourths of the whole number under one year, and very nearly a 
third of those between 1 and 15 years of age. 

Of a sei-ies of 23 cases that we have met with, 5 were fatal. All of 
these were under 5, and 3 under 1 year of age. 

The amount of the eruption governs the prognosis to a great degree. 
As the number of pocks is abundant or otherwise, — as the case is a dis- 
crete, moderately full, semi-confluent, or confluent one, — so is the 
dang^\ Cases of full confluence are almost as fatal as malignant scar- 
latina. Few children escape in the confluent form. A moderately full 
eruption, and of course a discrete one, is favorable. The hemorrhagic 
form is, almost without exception, fatal. Varioloid rarely kills. Under 
15 3'ears of age we have never seen a fatal case of it. In one case only 
have w^e known it to be dangerous. 

The favorable symptoms in any case of variola are the occurrence of 
the disease in children previously in good health and over one year of 
age; the absence of any violent nervous symptoms during the initial 
stage; a proper duration of the first stage; and the subsidence of the 
fever after the appearance of the eruption. When, in addition to these 
circumstances, the secondary fever is not too violent, and no complica- 
tion arises, there is but little doubt that the patient will recover. 

The unfavorable sj^mptoms are the occurrence of the disease at a 
very earlj- age; the existence of severe nervous symptoms during the 
first stage; the occurrence of a thick and abundant eruption upon the 
face, indicating a probably confluent case ; continuation of the fever 
after the appearance of the eruption, or a merely slight subsidence of 
it; delirium and other nervous sj^mptoms during the secondary fever; 
and any irregularity in the appearance ol the eruption, as paleness in- 
stead of the usual red color, a livid or purplish color of the pustules, im- 
perfect development of the pocks, or their sudden shrinking without 
diminution of the general sj^nptoms. The occurrence of the signs 
which mark the hemorrhagic form, as petechiae and local hemorrhages, 
stamp the case as almost necessarily fatal. It is scarcely necessary to say 
that many of these symptoms are indicative of the existence or threat- 
ened production of some complication, upon the nature of which 



798 SMALL -POX. 

must depend, after all, in great measure our prognosis. The complica- 
tions most apt to occur have already been considered in a previous 
section. 

Treatment. — The treatment must be regulated by the type of the 
case under charge. It will vary, therefore, from a mere quiet expect- 
ancy throughout, to the vigorous use of such means as moderate fever, 
abate nervous agitation, and allay suffering in the early stages, with the 
l^ereraptory exhibition of stimulants, tonics, and nutritious foods, in the 
period of eruption and maturation. 

In the varioloid of children over eight or ten years of age, during the 
initial fever, rest in bed, light diet, and the use of sweet spirit of nitre, 
in iced lemonade,, often suffice. Should there be much restlessness, in- 
somnia, or pain, solution ^of citrate of 2:)otash, with small doses of lauda- 
num or paregoric, may be given. When the eruption appears, if it be 
slight, and the fever disappears, nothing more is necessary than to 
keep the diet moderate and seclude the patient in one room, for the 
sake of others, until the crusts have fallen. If the eruption be more 
copious, enough to cause a good deal of irritation and restlessness, a 
warm bath at night, especiallj' with some bran added to it, and the 
application through the day of an ointment of glycerin and cold cream, 
with a mild opiate at night, are all-sufficient. 

In the variola of un vaccinated children, the treatnaent must also 
depend on the type of the symptoms. In the initial stage, when the 
fever is high, the child must be confined to the breast, if it is still 
nursing, and, if weaned, it is to be kept upon a proper mixture of milk 
and water, with lime-water, and uj^on chicken or beef tea, for food. 
Cold water must be frequently offered to the child at all ages, and it 
should be allowed to take all it desires. A tepid bath morning and 
evening, or even three times a day, if the child does not resist, is very 
soothing, and tends to reduce the heat. Spongings with tepid or cool 
water, from time to time, according to the degree of heat, and the 
effects of the application, may be used, if the bath terrifies or fails to 
reduce the fever. 

Diaphoretics, and especially the citrate of potash, with sweet spirit 
of nitre, and very small proportions of laudanum, should be adminis- 
tered in this stage. Or the spirit of Mindererus may be given, — twenty 
to thirty drops, with ten drops of nitre and five of paregoric, in a table- 
spoonful of iced water, every two hours, to children of six months to 
two year!?. For older children the doses must be enlarged. 

When there is, as often happens, great agitation of the nervous 
system, as shown bj' jactitation, insomnia, and mild or active delirium, 
some remedy should be given to control these symptoms. If the citrate 
of potash and opium fail to relieve these conditions, the best remedy is 
bromide of potassium, one to two and a half grains, with one to two 
drops of deodorized laudanum, at the age of one to three years, every 
two hours until rest is obtained, or until three or four doses have been 
given. After the age of four years the proportion of the bromide may 
be doubled. 



TREATMENT. 799 

"When great beat and swelling of the skin, severe headache, and signs 
of congestion of the lungs or brain, exist, cold applications to the 
head, with hot mustard foot-baths, may be used with the diaphoretics. 
If. in older children, the headache or pain in the loins be very severe, 
a few dry cups or a sinapism may be applied to the back of the neck 
or loins. 

If the bowels are not moved spontaneousl}^, a moderate laxative 
ought to be used, as syrup of rhubarb or castor oil, or an enema may 
be ordered. Purging with large doses of cathartics, must be avoided 
at all ages. 

In the eruptive stage the treatment must vary with the type of the 
eruption and the constitutional peculiarities of the patient. It may be 
laid down as a rule that, the more copious the eruption, the more care- 
fully should the strength be husbanded, and the vitalitj^ supported, to 
enable the patient to pass through the long and exhaustive processes of 
maturation and desiccation necessary to a cure. 

If the eruption come out slowly and tardily, and the extremities be 
cool, even though the body is hot, hot mustard foot-baths, or warm 
baths, with hot drinks, as milk and water, hot broths, and small quan- 
tities of brand}', ought to be employed, and are often very useful. 

If the eruption be discrete and moderate in amount, nothing but rest 
in bed, simple sustaining foods, and some local remedy to allay cutane- 
ous irritation, as an ointment or an occasional warm bath, will be nec- 
essary until the secondary fever appears. When this arrives, the same 
means, in the form of diaphoretics, anodj^nes, and nervous sedatives, 
should be used as in the initial stasje. In the sta£i;e of maturation the 
strength must be sustained by a diet adapted to each particular case. 
If the patient be feeble, and therefore much reduced by even a moder- 
ate eruption, he must have brandy added to his milk, or wine-whey, 
from time to time, increased doses of beef or chicken soup, if he can 
take them, and, if old enough, eggs, or egg-nog. Quinia and muriated 
tincture of iron should be used as in confluent cases, of which we shall 
speak directly. 

In the semi-confluent and confluent cases all must be done to sustain 
the strength and vitality. From an early period of the eruptive stage, 
alcohol, quinia, and iron, must be employed. From twenty to thirty 
drops of brandy, in a wineglassful of milk, may be given every two 
hours, and two or three tablespoonfuls of thin beef tea, every alternate 
two hours, at the age of two or three years. After the age of five, 
these quantities may be doubled. To infants, brandy, in doses of ten 
to twenty drops, may be given every two hours, in breast-milk, or in 
warm water and sugar. Quinia, in doses of half a grain, at a year old, 
and one grain at four and five years, with or without muriated tincture 
of iron, oyght to be administered every four hours. It is best to choose 
the four-hour interval, because of the difficulty there is in giving fre- 
quent doses to children. If the stomach will not retain the iron and 
quinia mixed together, the quinia may be used in suppository, two 
grains every four hours, and the tincture of iron in doses of two to five 



800 SMALL- POX. 

drops, according to the age, ever}' two hours, in syrup of ginger, or in 
combination with dilute acetic acid and solution of acetate of ammonia, 
as proposed in the article on scarlet fever. 

The condition of the pharj^nx and larj^nx present in confluent small- 
pox, as described in the article on symptoms, constitutes one of the 
great difficulties of the disease. The patient suffers so much in the 
act of swallowing, the respiration is so interfered with when he attempts 
to drink or eat, that it ends in his taking but little, and, at last, almost 
nothing. Here ice should be given, iced flaxseed tea and iced brandy 
and water, or frozen beef-tea. A solution of chlorate of potash may also 
be tried. Lemonade may be used, and a warm poultice to the throat is 
to be recommended. Still we must persevere, as small quantities are 
better than nothing, and we maj" emplo}' nutritive injections of beef- 
tea, of milk, or of egg and milk. 

If the patient survives the stage of eruption, we must continue the 
tonics, stimulants, and nutritious food through the decline of the disease. 
During the latter period something must be done to allay the itching, 
burning, and irritation of the skin. If the patient is not too weak, a 
flaxseed or bran bath is very soothing, or we may use lime-water and 
sweet oil liniment, or glycerin and cold cream ointment, applied with a 
large camcl's-hair brush frequently. 

In hemorrhagic small-pox, which is almost always fatal, we know 
nothing better to recommend than the treatment just advised for the 
confluent form. 

Treatment of Complications. — If complications occur in the course of 
the disease, they must be treated always, with a full consideration of 
the primary importance of the general disorder. The angina and 
lar^'iigitis of confluent cases can scarcely be looked upon as complica- 
tions. They belong to the disease. We have already alluded to their 
treatment, and may refer the reader to what has been said of the same 
series of symptoms in scarlet fever. In pleurisy or pneumonia we can 
do nothing better than persevere with the measures most proper to 
combat fever. Pain may make it necessary to use opium in full doses. 
Counter-irritation is not to be thought of because of the eruption, and 
even cataplasms, which are so useful in ordinary pleurisy and pneu- 
monia, are objectionable here. 

The treatment of the ophthalmia which so often threatens, and some- 
times occasions great or irreparable injury to the ej^e, is very impor- 
tant. Niemeyer says that much may be done to prevent the develop- 
ment of a severe eruption on the conjunctiva by the assiduous employ- 
ment of cold water compresses, or, still better, by compresses moistened 
with a weak solution of corrosive sublimate, one of one grain to six 
ounces of distilled water. When ulcerations occur upon the cornea, 
they ought to be touched, if this be practicable, with solid nitrate of 
silver sharpened to a point, or with a fine camel's-hair pencil which 
has been moistened and rubbed over the nitrate of silver crystal to in- 
sure a caustic solution. When it is impossible to apply the solid caustic 
or the brush, we must resort to some collyrium. This may consist of 



TKEATMENT. 801 

a solution of nitrate of silver, a grain to the ounce; or of one or two 
grains of sul23hate of zinc, with twenty or thirt}^ drops of wine of opium, 
dissolved in an ounce of rose-water, two or three drops of either of 
which may be introduced into the eye, morning and evening. An ex- 
cellent collyriuni is one composed of twelve grains of borate of soda, 
one grain of sulphate of zinc, a drachm of camphor-water, to seven 
drachms of distilled water. 

Catarrh of the intestine must be treated by the most careful attention 
to the diet, by emollient and anodyne injections, and by the internal 
administration of astringents, and small doses of opiates. When the 
diarrhoea is severe, and the stools mucous and bloody, we may use with 
advantage the nitrate of silver by enema, as recommended in the article 
on entero-colitis. 

The treatment of the convalescence is important. The same rules 
apply here as in other infantile and children's diseases. 

Ventilation and Disinfectants. — It is even more important in this dis- 
ease than in others, for the ph3'sician to see to it himself that the rooms 
occupied by the j^atient, and the house of which they form a part, shall 
be well ventilated, and that so soon as the eruption becomes purulent, 
and its exhalations more or less fetid, proper disinfectants shall be ap- 
plied. This is necessary, not only for the good of the patient, but also 
for the safety and comfort of the other inmates of the house. The 
best ventilation in winter is that procured by an ojDcn fire, or, if this 
cannot be had, by a stove. If the room can be warmed only by a furnace, 
the windows must be very carefully opened from time to time, so as to 
supply fresh air, and yet avoid currents flowing over the patient. In 
summer, of course, the windows must be open. 

The best disinfectant is Labarraque's solution. If this cannot be 
had, or if more than one be desired, chloride of lime in saucers, wetted, 
or a mixture of equal parts of impure sulphate of iron and of chloride 
of lime, wetted, and placed in saucers, in the entries and passages of 
the house, are very eflicient. 

Before terminating our remarks upon the subject of small-pox, it will 
be proper to give some account of the treatment of the eruption which 
has been recommended and practised, with a view to prevent the scar- 
ring and disfiguration which so often result from the ravages of the 
disease. Of the different means that have been employed with this 
view, there are two which are chiefly relied upon at present. One is 
to cauterize the pustules with nitrate of silver, and the other to 
make a mercurial application upon the part where it is desirable to 
cause the abortion of the eruption. The cauterization has been per- 
formed in two modes; by the application of the caustic to each pustule 
separately, or to masses of the eruption without puncturing the cuticle. 
It appears, however, that, the first-named method is much the most 
preferable. To succeed perfectly, it is necessary to touch the derm 
forming the base of the pustule; so that the best plan is to remove or 
lift up a portion of the top of the vesicle with a lancet, and then to in- 
troduce into its interior the sharpened point of a stick of caustic. This 

51 



802 SMALL-POX. 

operation is certainly successful only when performed on the first or 
second day of the eruption, though MM. Riliiet and Barthez have known 
it to answer as late as the third and fourth, or even fifth day. The 
process of cauterization is productive of acute pain, but does not in- 
crease the local inflammation, according to the authors just quoted, at 
least when applied to a small number of the pocks. They state that 
when applied to the pustules seated upon the edges of the eyelids, it is 
almost incredible to behold how great is the diminution of the oedema 
of those parts in a single day. The conclusion of these gentlemen is, 
that individual cauterization of the pustules with nitrate of silver does 
certainly cause them, as well as the surrounding tumefaction, to abort, 
and prevents them from leaving cicatrices. 

This plan is, however, manifestly inapplicable to any but cases of the 
discrete form, where the vesicles are not very numerous. 

The other method which has been employed to cause the abortion of 
the pustules, and thus prevent disfiguration, is, as has been stated, the 
application of some one of the mercurial preparations. The effects of 
this treatment are said to be an almost certain arrest of the develop- 
ment of the eruption, when it is used from the first or second, or not 
after the third day ; the vesicles and pustules remaining small and iso- 
lated, and not assuming, or else soon losing,"the umbilicated character. 
When applied early, while there are as yet but few vesicles formed, it 
prevents the development of new ones, and diminishes the accompan^^ing 
swelling and soreness. When the application is removed on the seventh 
or eighth day, it is found that desiccation has occurred imperfectly^ the 
surface presenting small soft scabs, or little whitish, soft elevations, con- 
sisting of the pseudo-membranous substance situated between the true 
skin and the new epidermis, the old cuticle having generally peeled off 
with the plaster. In some places a light rose-colored surface alone 
remains. 

In regard to the success of this treatment in preventing disfigura- 
tion, we may quote the statement of MM. Riliiet and Barthez, that 
none of the patients upon whom they saw it tried presented any cica- 
trices, though several had had confluent small-pox, which pursued its 
usual course on the parts not covered by the application. Dr. Stew- 
ardson, of this city, made a considerable number of trials of this treat- 
ment at the Small-pox Hospital of this city in 1841-42. He gave his 
conclusions in the following words (Am. Jour, Med. /Scz., January, 184B, 
p. 86-7) : " From these experiments, it seems pretty evident that the 
mercurial plaster has a decided influence upon the small-pox pustules, 
preventing more or less completely their perfect maturation, and dimin- 
ishing the concomitant swelling and soreness, the process of desicca- 
tion being completed without the formation of thick scabs, and the 
resulting cicatrices less marked than when the process of suppuration 

was left to pursue its natural course That, by its use, pitting 

may be entirely prevented, or the mortality from small-pox materially 
lessened, seems to me very doubtful, although had all the precautions 



TREATMENT. 803 

above-mentioned been taken, it is not improbable that the effects would 
have been still more decided." 

The use of the mercurial application is attended with some incon- 
venience. In the first place it is difficult to keep it accurately applied, 
particularly in children, in consequence of the unpleasant sensations it 
occasions. In the second j^lace, it not very unfrequently, according to 
MM. Eilliet and Barthez, produces an eruption of hydrargyriasis or 
mercurial roseola, in about eight or fourteen days after the variolous 
eruption, or four or ten after the application of the remedy. M. Eaj'er, 
however, states this effect to be a rare one. 

Dr. Stewardson sa3's that he thinks no apprehension need be felt as 
to constitutional affection from the mercurj^for scarcely ever were the 
gums even touched. One of ourselves, however, when in Paris, in 1840, 
saw this eftect produced in a young girl at the Children's Hospital. 

The method of its application is different in different hands. The 
French generally employ the emplastrum do Yigo cum mercurio. Dr. 
Stewardson prefers the strong mercurial ointment, either pure or rubbed 
down with an equal bulk of lard, spread upon a piece of thick muslin. 
The muslin is to be cut into the shape of a mask, with apertures for the 
eyes, nose, and mouth. It is secured upon the face by means of strings 
attached 'to its margin and tied across the back of the head and neck. 
It is important always for the success of the measure, that the applica- 
tion should be kept in close contact with the skin. To insure this, he 
employed a separate piece of muslin for the nose, which is the part 
most difficult to fit. With the same view, the French authors recom- 
mend that the plaster should be cut in pieces to suit the different por- 
tions of the face, making one for the forehead, and others for the cheeks, 
sides and back of the nose, and upper and lower lips. Any spaces that 
may remain are to be covered with other portions of the plaster, and 
the whole secured with strips of diachylon. On account of the diffi- 
culty of applying the mercurial plaster, the following ointment was 
compounded by the apothecary of the Children's Hospital at Paris, and 
has been found to answer very well : 

R. — Mercurial Ointment, 24 parts. 

Yellow Wax, ........ 10 parts. 

Black Pitch, 6 parts.— Mix. 

The application ought to be confined to the face, as that is the part 
which it is most important to save from disfiguration, and as it is better 
not to use it upon a larger surface than necessary, lest it might occasion 
the mercurial roseola, or possibly salivation. As a general rule, four 
or five days are sufficient, according to G-uersant and Blache, to leave 
it in contact with the skin, in order to avoid the bad effects just re- 
ferred to. 

The object sought in these applications being, to a great extent, to 
protect the vesicles from contact with the atmosphere, it has been ad- 
vised to paint a saturated solution of gutta percha in chloroform, over 



804 VACCINE DISEASE. 

the neck and face, so soon as the papular eruption is fully out. This 
plan was tried in five of our own cases {loc. cit., p. 345), two of which 
were discrete, and three confluent, and with very satisfactory results. 

To conclude this matter we will add that Niemeyer states that Skoda 
prefers compresses moistened with solution of corrosive sublimate (gr. 
ij-iv to water ^vj) to mercurial plaster, which induces an injurious ele- 
vation of temperature. He also says that Hebra rejects both mercurial 
plaster and solution of corrosive sublimate, as well as collodion, and 
touching the individual pocks with nitrate of silver, and that he has 
come to this decision from the observation in his wards, that the pocks 
do not leave cicatrices any oftener since he has ceased to employ these 
remedies than when he used them. He (Hebra) applies only cold water 
compresses, which, while the skin is tense, relieves the patient, although 
they do not protect the skin from destruction. 



AETICLE YIII. 

VACCINE DISEASE. 

Definition; Synonyms; History. — The vaccine disease is an affec- 
tion produced by the inoculation of the virus of variola, modified by 
passing through the system of the cow. 

The proofs which exist as to the truly variolous nature of the vac- 
cine disease in the cow, are altogether incontestable; so that we must 
regard the vaccine disease in the human subject merely as a remarkably 
modified form of variola. 

It is susceptible of propagation from individual to individual by in- 
oculation, but is contagious in no other way, and it possesses the in- 
valuable quality of protecting, with very great, though not with abso- 
lute certaint}^, those through whom it has passed, against small-pox. 

Besides the name given above, it is known by the titles of cow-pox, 
kine-pock, vaccina, and vaccinia. 

Some knowledge of the nature of the vaccine disease, and of its 
power to protect the human constitution against small-pox, has been 
found to have existed in different parts of the world, but there can be no 
doubt that we owe to the genius and patient research of Dr. Jenner the in- 
estimable blessing of vaccination, since it was by him that its marvellous 
virtue was first demonstrated and proclaimed to the world. Dr. Jenner 
learned, at an early period of his life, that there existed a popular belief 
in Gloucestershire, England, that persons who had contracted a peculiar 
vesicular disease from the udder of the cow, were thereby protected 
from the attack of small-pox. Becoming convinced by a long course 
of patient observation, that this belief was founded in fact, he deter- 
mined at last to try whether the disease might not be transmitted from 
one person to another, and thus increase immeasurably the utility of 



SYMPTOMS — COURSE. 805 

this wonderful protective means. On the 14th of May, 1796, accord- 
ingly, he vaccinated a child eight years old with matter taken from the 
hands of a milker who had received the disease from the cow. The ex- 
periment succeeded perfectly, the child having received and passed 
through the disorder in the most satisfactory manner. On the 1st of 
July following, this child was inoculated with variolous matter, and re- 
sisted the contagion entirely, as Dr. Jenner had expected. It was not, 
however, until two years later, in 1798, after additional experiments, 
that the results of his researches were published to the world. From 
this time the belief in the utility of vaccination and its application in 
practice spread rapidly throughout England. In 1799 it was introduced 
into this country ; in 1800 it reached France, and in the course of a 
very few years extended to all civilized nations. 

Symptoms; Course. — It is very important for the physician to be 
thoroughly acquainted with the appearances presented by the vaccine 
disease in its various stages, since he is to judge by those appearances 
whether the subject has had the disease in such perfection as to derive 
all the benefit from its protective power which it is possible for it to 
impart. 

The first effect of the puncture by which the virus is introduced into 
the tissues, is to produce a very slight redness at the point where the 
operation is performed. This redness usually disappears within twenty- 
four hours, and there is left merely a little mark or scab at the point of 
insertion. On the third day after the operation we first begin to per- 
ceive the specific effects of the virus, in the shape of a small, hardened 
point at the seat of the wound, surrounded by a faint, erythematous 
redness. Over this hardened point, which grows gradually larger, the 
cuticle is elevated on the fifth day into a vesicle, by a thin, transparent, 
and pearl-colored serous exudation. This vesicle soon becomes umbili- 
cated, so that by the following day, the sixth, the depression in the cen- 
tre, constituting the umbilicated character, is generally perfectly mani- 
fest, and at the same time 'the vesicle is surrounded by a very narrow 
ring of inflammation. The vesicle continues to increase in size, until 
on the eighth or ninth day it has reached its highest degree of develop- 
ment. At this stage the vesicle or pock is large, usually about one- 
third of an inch in diameter, and it projects very considerably above 
the general surface. Its shape is circular, as a general rule, though 
not unfrequently it is oval, this depending apparently upon the mode 
in which the puncture has been made. The color of the pock is dull 
white or pearly, or sometimes it has a yellowish tint. The quantity of 
fluid contained in the cavity of the vesicle differs, of course, according 
to its size. The structure of the pock is found, upon careful examina- 
tion at this time, to be cellular, the number of cells amounting com- 
monly to eight or ten ; very often there is a small, dark-colored scab 
on the ver}^ centre of the vesicle, even at this period, though in other 
instances this is absent, the surface of the vesicle being formed exclu- 
sively of thin and transparent cuticle. The scab just alluded to has 
seemed to us to consist of the little incrustation, formed at the point 



806 VACCINE DISEASE. 

where we had introduced the virus by the drying up of the minute 
quantity of blood escaping after the puncture, and of the dissolved virus 
which had not been absorbed. We have often noticed that when the 
small scab just alluded to has been rubbed off the arm on the second 
day, the vesicle has presented no scab as early as the eighth day. On 
the eighth day the little ring of redness at the base of the pock, which 
has hitherto been very small and narrow, begins to enlarge so as to 
form the areola. This increases during the ninth and tenth days, form- 
ing a brilliant scarlet or dark-red inflammatory circle of about two 
inches in diameter, and constituting one of the most strongly marked 
features of the vaccine disease. The color of the ring is most intense 
at the edge of the vesicle, and then fades gradually to its outermost 
boundary. On the ninth and tenth days, in connection with the areola, 
the skin and cellular tissue on which the vesicle is seated, and that for 
a short distance beyond the margin of the latter, become hardened and 
tumefied, forming a solid knot or lump in the derm, like the base of a 
furunculus. The inflammation which causes the areola is often so intense 
as to occasion the production of vesicles, which are almost always dis- 
coverable with the aid of a lens, and are sometimes distinctly visible to 
the naked eye. On the tenth day the disease is usually at its height, 
and it is then, of course, that all its peculiar characteristics are most 
strongly marked. At this time the child, when of an age to describe 
its sensations, will often complain of heat, itching, and pain in the in- 
flamed spot; the arm is heavy and not willingly moved, or it is moved 
with care and caution; there is, in a good many instances, some irrita- 
tion and swelling of the axillary glands, and very frequently a decided 
febrile reaction may be noticed. In other cases, on the contrary, none 
of these symptoms will be present. The child is gay and cheerful, its 
movements free, quick, and unembarrassed, and it seems in all respects 
to be in its ordinary condition of health. 

From the tenth day the disease begins to subside. The areola fades 
so as to have nearly disappeared by the fourteenth day; the fluid con- 
tained in the vesicle is gradually converted into pus, and the cellular 
structure of the pock is broken down so as to form, by the thirteenth 
day, but a single cavity, in which the pus is contained; the process of 
desiccation is going on rapidly during this time, so that about the four- 
teenth day the vesicle has disappeared, and in its place there is a firm, 
bard scab, of the shape and size of the vesicle. This scab continues to 
harden for some days longer, and at the same time contracts somewhat 
in size and grows darker in color, until at last it is of a very dark brown 
or mahogany tint. It separates gradually from the tissues beneath, the 
separation beginning at the circumference, and falls off usually about 
the eighteenth or twenty -first day, leaving beneath a small ulcer, which 
soon heals, or else a cicatrix of the shape and size of the pock. The 
cicatrix is at first of a deep red or purple color, but fades gradually, 
until it becomes much whiter than the surrounding skin. The scar 
left by the vaccine disease is very characteristic, and is often, though 
not by any means invariably, indelible. To be at all depended on as a 



IRREGULARITIES AND ANOMALIES. 807 

mark of the disease, the scar should be small, circular, of a smooth and 
somewhat shining appearance, and it should exhibit radiations and 
little depressions or pits. The depressions are supposed to have been 
caused by the cells constituting the pock in its early period. 

There is rarely more than a very slight constitutional disturbance 
attendant upon the course of this disease. About the eighth day, a de- 
cided febrile reaction, attended with some unusual warmth of the sur- 
face, restlessness at night, and fretfulness of the temper, is often ob- 
served. In a few instances we have noticed distinct disturbance of the 
health about the third and fourth days; amounting onl^^, however, to 
unusual irritability and discomfort through the day, and to wakefulness 
or disturbed sleep at night. 

Irregularities and Anomalies. — We have now described the regu- 
lar course of a vaccination — that wHiich it pursues in a large majority 
of the cases. Certain variations from the above standard or typical 
course are frequently, however, met with, and require some notice. 
These variations may consist merely in the degree of severity of the 
local and general sj^mptoms, or in the appearances presented by the 
pock, without affecting at all the validity of the disease; or they may 
concern the duration of the phenomena; or, lastly, they may be such 
as to call in question the validity of the disease, leaving us in some doubt 
as to whether it has protected the constitution against variolous attacks 
or not. 

The severity of the local inflammation occasioned by the vaccination, 
and that of the general symptoms also, varies often to a considerable 
extent. In some instances, and especially when the virus employed 
has been procured recently from the cow, the specific inflammation 
proves very severe. We have seen the arm intensely red, and very 
considerably swelled, from the shoulder to an inch below the elbow, 
while at the same time the axillary glands were tumefied and tender, 
and the child very feverish and uncomfortable. This happened in 
three children, in all of whom we had employed the same virus; 
w^hich, as we afterwards learned of the person from whom we obtained 
it. had been taken quite recently from the cow. It produced the same 
violent inflammation, moreover, in several other subjects in whom it 
was employed. 

If the vesicle happens to be broken by accident soon after its forma- 
tion, its appearances during the subsequent progress of the disorder 
will often be very different from those exhibited in subjects in w^hom no 
such accident occurs. The vesicle loses a portion of its contents; it 
becomes conoidal and irregular in shape, instead of being circular and 
umbilicated; it does not exhibit the pearly white and diaphanous color 
which belongs to it, but is yellowish and opaque; the areola is often 
premature and irregular in shape, and the scab is frequently small, un- 
even on the edges, and falls off at an unusually early period. 

Occasionally there is observed in the course of cow-pox a papular 
eruption over the body of the child. This occurs usually between the 
ninth and twelfth days. 



808 VACCINE DISEASE. 

It is quite common for the disease to be retarded in its progress. 
The delay general!}^ takes place in the appearance of the vesicle, this 
not showing itself until the sixth or eighth day, or, in some rare in- 
stances, not until the sixteenth, or even the twentieth, or forty-sixth 
day. The longest retardation that we have met with has been seven 
days. In this kind of retardation, the disease usually runs through its 
regular and natural phases after the vesicle has once made its appear- 
ance. In another kind of retardation the delay occurs in the vesicu- 
lar and pustular stages of the affection, the papule appearing at the 
ordinary time, but the disease not reaching its height or maturity until 
the eleventh or twelfth day. 

The forms of variation from the ordinary course of cow-pox just de- 
scribed, do not seem to be connected with any diminution in the pro- 
tective power of the disease. 

It sometimes happens that the operation of vaccination gives rise to 
a disease totally unlike the true vaccine disease, one which does not 
protect against small-]30x, and which has therefore been called spurious 
vaccine disease. 

It was formerly the custom to describe quite a variety of appear- 
ances as indicating with greater or less probability a spurious disease. 
Of late years, however, it is generally admitted that the spurious pock 
is of much less frequent occurrence than was at one time supposed, 
and that, when it does occur, its characters are so marked as to make 
it easy of recognition. In fact, it happens in a very large majority of 
cases, that the vaccination either fails entirely, the puncture being pro- 
ductive of no other results than those which would naturally flow from 
a slight wound of the skin, or else that it is followed by a true and 
easil}' recognized vaccine pock. 

When, however, the operation is followed immediately or within a 
day or two days by inflammation, and the appearance of a pustule, 
without the previous production of a vesicle; when this pustule is 
irregular in shape, yellow in color, acuminated, easily broken, and ter- 
minating in a soft, yellowish, ragged-looking crust, which falls off upon 
the fifth, sixth, or seventh day, there is assuredly reason enough to call 
the vaccination spurious, and it becomes the imperative duty of the 
practitioner to regard it as such until subsequent and repeated trials 
with other and fresh virus^ have proved the child to be protected. 

Diagnosis. — There can be no diflficult}- whatever in distinguishing 
the vaccine disease when it occurs in its regular form. The successive 
phases through which the eruption passes, and the particular appear- 
ances which it presents in each stage, are so unlike all other diseases, 
except, indeed, small-pox, as to render it very easy of recognition. 

Sometimes, however, there is a little difficulty in determining whether 
the eruption is spurious or regular. But this rarely happens except 
under circumstances in which we should expect some modification in 
the phenomena of the disease, to wit, when its course is interfered with 
by the effects of a previous vaccination, or of an attack of variola. The 
irregularities arising from these causes are such as might be anticipa- 



PEOTECTIYE POWERS. 809 

ted. and will be described in the article on revaccination. Whenever^ 
however, the disease fails, in any important respect, to exhibit the per- 
fect attributes of a well-marked pock, both as regards its time of devel- 
opment, its changes, and its particular appearances at each stage, in a 
child not previously vaccinated, nor having had small-pox, the only 
wise and prudent plan to follow is to repeat the operation a few weeks 
after the doubtful one, so as to test thereby the protective power of 
the first. 

Protective Powers. — Though vaccination in infancy has not proved 
a sovereign protection against small-pox, as was at first hoped and ex- 
pected, the security it does afford, w^hen properly used, against one of 
the most loathsome and dangerous of diseases, is so nearly perfect that 
the thought of its benevolent power ought to rouse every feeling of 
thankfulness of w^hich the human heart is capable. It has come to 
pass within a few^ years, here and there in the world, and we know 
this was the case in Philadelphia, that some persons have begun to 
question the real value of vaccination. Such persons always seemed to 
us the most crotchety and foolish of mankind, and since small-pox ex- 
hibited its powers here, as it did in the epidemic of 1871-2, we imagine 
those very persons are quite ready once again to thank Providence for 
its great boon, and to do true homage to the great discoverers of vacci- 
nation. 

As to the protective powers of vaccination, we have had proof abun- 
dant, in our own experience alone, to satisfy us that this is complete 
when it is properly applied. We have never seen life lost or the face 
disfigured, during thirty-two years of experience, in any one who had 
been well vaccinated in infancy, and then successfully revaccinated at 
puberty. We had never seen a fatal case of small-pox in a subject 
lUnder 43 years of age, who had been w^ell vaccinated in infancy, until 
the late epidemic, though we had seen two who had it severely enough 
to pock-mark them. We knew that such cases occurred, but none had 
occurred in our own practice; and our experience in the late terrible epi- 
demic has but confirmed our faith in the powers of vaccination. During 
its prevalence w^e saw no severe nor dangerous varioloid or variola in 
children under 10 and 12 years of age. It was not except among those 
over 15 and 20 years of age that we began to see and hear of dangerous 
cases of the disease; and after successful revaccination, even in those 
most exposed, we saw not a case even of varioloid, much less of severe 
variola. We could, had we the space, cite particular instances in our 
own practice in proof of the absolute protection afforded by revaccina- 
tion, but deem it best to give some facts illustrative of this power from 
the hospital experiences of the late epidemic. 

In the report made to the. Board of Health, of this city, by Dr. Welch, 
of the Municipal Hospital, during the epidemic of 1871-2, are some facts 
which show most strikingly the power of vaccination. At page 9 are 
given the following cases : 

"Case 1. Child, aged two years; vaccinated in infancy; two good 



810 VACCINE DISEASE. 

cicatrices; came in with mother, who had small-pox; sixteen days in 
hospital ; no disease. 

"No. VI. Infant, astat. 10 months; not vaccinated; admitted Febru- 
ar}^ 10th, along with its mother, who had varioloid, and from whose 
breast it was nursing; vaccinated same day. February 16th. — Two 
convulsions. 17th. — Perfectly well again; vaccination taking well; 
fourteen (14) days in hospital; no disease. (This child returned to the 
hospital with measles.) 

"No. IX. Child, set. 7 years; vaccinated six months ago; fair cica- 
trix; eleven (11) days in hospital; no disease. 

" 'No. X. Child, set. 8 years ; vaccinated six months ago ; fair cicatrix ; 
eleven (11) days in hospital; no disease." 

At page 12 Dr. Welch states another very interesting fact, which co- 
incides with the experience of the London Small-pox Hospital. He 
says : " In this connection we might add that the physician in charge, 
his two assistants, the matron — who has been connected with the hos- 
pital for twenty-four years — the chief male nurse, and a number of 
others employed at the hospital during the epidemic, were protected 
only by vaccination and revaccination. Indeed, not a single person 
connected with the hospital, who had been revaccinated, contracted 
the disease ; while, on the other hand, some three or four of the nurses, 
who had been affected by small-pox previously, took the disease a sec- 
ond time." 

How any one can read such facts as these, and they might be indefi- 
nitely increased, and yet refuse a child the boon of vaccination, is be- 
yond our comprehension. 

In the last edition of this work we endeavored to show the necessity 
and propriety of revaccination. Hereafter we shall advocate revacci- 
nation in all cases, no matter how perfect the first vaccination may be 
stated to have been, or how perfect the cicatrix or cicatrices. At the 
age of fifteen, or as soon afterwards as possible, all young persons ought 
to be revaccinated. There should be no waiting for an epidemic or for 
direct exposure to infection. The operation ought to be performed as 
regularly as the primary vaccination. 

There is now a host of evidence on this point, but that which is given 
by Dr. Welch, in the report just quoted, of facts demonstrated by the 
late epidemic in this city will be all-sufficient. 

"With reference to the practical efficacy of revaccination," he says, 
"the hospital record shows as follows : Among 2377 cases of small-pox 
admitted during the epidemic, only 36 are said to have been revacci- 
nated, of which 4 died. But by subjecting these cases to a careful anal- 
ysis, we find as follows : Seventeen (17) were revaccinated at a distant 
period, some as far back as thirty-one (31) years; five (5) had not been 
revaccinated until after exposure; seven (7) were said to have been 
successfully revaccinated, but were unable to exhibit any cicatrices as 
the result; sixteen (16) bore upon their arms very poor and uncharac- 
teristic scars, some of which, indeed, were scarcely visible; five (5) pre- 



SUSCEPTIBILITY TO THE DISEASE. 811 

sented fair cicatrices; and only three (3) were able to show good cica- 
trices. 

'•Of the four (4) who died, two (2) occurred among those without 
cicatrices, one among those revaccinated after exposure, and one among 
those showing poor and uncharacteristic scars. 

'^All the cases which bore upon their arms unmistakable evidence of 
successful revaccination, suffered from the mildest form possible of the 
disease. Indeed, three (3) of these cases exhibited an eruption of doubt- 
ful character, and have therefore been recorded as cases of varioloid (?). 
The eruption on three (3) others did not advance beyond the papular 
stage, and on seven (7) it was barely vesicular." 

It is unnecessary to add anything more as to the protective power 
of the vaccine disease against small-pox. Those who are not convinced 
by such facts as these, would not believe one though he rose from the 
dead. 

Period of Performance. — The period usually chosen for the per- 
formance of this operation, is soon after the age of three months. If, 
however, the infant be exposed to the contagion of variola, it is neces- 
sary to perform it immediately, even upon the first da}^ of life ; and in 
such cases the protective power is as perfect, and the local or constitu- 
tional irritation little greater, than when the operation has been de- 
ferred to the usual time. 

Susceptibility to the Disease. — The susceptibility to the vaccine 
disease varies greatly in different persons and different ftimilies, and is 
modified to a greater or less extent by the existence of other diseases 
in the individual at the moment of the operation. In some it is said 
never to be received, no matter how frequently or how carefully the 
virus may be inserted. In others it is received with difficulty, requir- 
ing several repetitions of the operation before it can be made to take; 
whilst in yet another class of subjects, the smallest amount of virus, 
when inserted in a careless and imperfect manner even, will produce 
the disease with the greatest certainty. Nevertheless a large majority 
of children take the disease after a single operation, if this be performed 
with ordinary care and nicety. No explanation of the different sus- 
ceptibilities of individuals to the disease can be given. The same dif- 
ference is known to exist in regard to other contagious and even epi- 
demic diseases, as measles, scarlatina, pertussis, variola itself, typhoid 
fever, and cholera. 

The susceptibility varies also in the same person at different times, 
without its being possible to ascribe this fact to any evident cause, since 
the child may appear on both occasions to be in the same condition as 
to health and other circumstances likely to influence its susceptibility 
to the contagion. Thus, we knew a child a few months old to be vac- 
cinated four times, twice by the late Dr. C. D. Meigs and twice by one 
of ourselves, each operation following rapidly the preceding one, with- 
out success, though the virus was known to be good from its having suc- 
ceeded in other subjects, and though it was changed each time. The 
child appeared to be in perfect health. There was no eruption of any 



812 VACCINE DISEASE. 

kind upon its surface, nor any other condition that could explain its 
insusceptibility. After the fourth operation, the attempt was suspended 
for about four months, then renewed, and with instant and entire suc- 
cess. In another case, the varying susceptibility of the same individual 
to the disease was still more strikingly exemplified. An infant, a few 
months old, was vaccinated four times in succession from the scab with- 
out success. It was then vaccinated with fresh lymph taken from the 
arm of an infant who was undergoing the disease. This also failed. A 
few weeks after this, the operation was again performed with the dried 
scab, and this time with perfect success. 

Certain eruptions existing previously upon the surface, have seemed 
to us to prevent the reception of a vaccination. The eczematous and 
impetiginous diseases of infancy and childhood have certainly had this 
effect in our experience, though M. Taupin (^Bict. de Medecine. t. xxx, p. 
406) is of the contrary opinion; he having found that the disease has 
been merely retarded when the operation was performed during the 
initial stage of the eruptive fevers, whilst its course was suspended even 
entirely when any of these affections occurred in a child already vac- 
cinated, to be resumed again after the cure of the eruptive fever. 

There is another circumstance concerning the supposed effects of other 
diseases on the vaccine affection, to which it will be well to draw atten- 
tion. We are sure there are few practitioners, having any considerable 
amount of business, but must have been annoyed, and injured perhaps 
in their reputations, by the notion so prevalent in the community that 
vaccination may impart to children other diseases. This prejudice 
exists particularly in regard to the chronic cutaneous eruptions of in- 
fancy and childhood, so that we have frequentlj^ had parents to insist 
to us that the impetiginous or eczematous disease under which their 
child might be laboring, has been caused by the vaccination, performed 
perhaps recently, or even months before. M. Taupin, quoted by ^IM. 
Guersant and Blache {Diet, de Med., t. xxx, p. 414), vaccinated a large 
number of children at the Children's Hospital in Paris, with virus taken 
from subjects affected with itch, scarlatina, measles, varicella, varioloid 
and variola, rachitis, scrofula, tuberculosis, chronic eruptions of the 
scalp, dartres, &c., without communicating to the patient any of these 
affections, either those of acknowledged contagious or non-contagious 
nature. A very curious case illustrative of this point is mentioned by Dr. 
Gregory in his ^^ Lectures on the Eruptive Fevers'' (Am. ed., New York, 
p. 270). " A child, who had been exposed to the infection of small-pox, 
was vaccinated. Both diseases advanced. A lancet charged with lymph 
from the vaccine vesicle produced cow-pox. Another lancet charged 
with matter from a variolous pustule, formed within the vaccine areola, com- 
municated small-pox." We mention the result of these experiments in 
order to show how little foundation there is for the popular notion above 
alluded to, and to give to the practitioner an argument with which to 
defend himself against the unjust accusations of those who may assert 
his vaccination to have been the cause of any disorder that may have 
followed upon it. Not that we would ourselves employ virus taken 



OPERATION. 813 

from a child suffering from disease of any kind whatsoever, since this 
is, to say the least, unnecessary, and ought to be avoided. Indeed, we 
have never employed a vaccine crust taken from a child who was not 
apparently in perfect health. The smallest amount of cutaneous erup- 
tion upon a child has always been sufficient reason with us to reject the 
virus afforded by such a patient, and as this must be the safest plan to 
adopt, it is of course the proper one. 

The still more serious charge has, of recent years, been made against 
vaccination, that it may be the means of transmitting constitutional 
syphilis. And there are well-authenticated cases in which the opera- 
tion has undoubtedly been followed by this terrible result. In every 
instance, however, so far as we are aware, in which the exact mode of 
the vaccination could be ascertained, it has been found either that the 
child from whom the virus was obtained, presented at the time evidences 
of constitutional syphilis, or that the virus had been impure, being 
mixed with blood or pus, which may have been the medium of infection. 
There is, indeed, no evidence whatever to show that the lymph or crust 
derived from a typical vaccine eruption, in an apparently healthy child, 
can possibly be the means of transmitting any constitutional disease. 
It is more prudent^ however, that if the lymph be used, it should not 
be taken after the eighth day of the existence of the vesicles; and that 
in obtaining it, all hemorrhage should be avoided. 

Mr. Jonathan Hutchinson {Med.-Chirurg. Transactions, for 1871) gives 
two series of cases which show the possibility of communicating s^^ph- 
ilis by means of vaccination. At page 322 he states his belief that the 
blood is the source of the contamination. He says: "There can, I 
think, be little doubt that in this instance it was the blood, and not the 
vaccine lymph, which was the source of contamination." At page 325 
he quotes, from a previous report, the following, amongst other conclu- 
sions : " That the blood of a child suffering from inherited syphilis can, 
if inoculated, transmit the disease with great certainty. 

" That it is quite possible for vaccine lymph and blood to be trans- 
ferred at the same time, and for each to produce its specific results, the 
effects of the syphilitic inoculation occurring subsequently to those of 
vaccination. 

"That it is quite possible to vaccinate successfully from a syphilitic 
infant in the stage of the utmost potency as regards its blood, without 
communicating syphilis." 

In regard to this most important point we have two statements to 
make : that we have never had occasion to suspect even that we have 
been the unfortunate instruments in communicating this disease in our 
own practice, and that we have always used the dried scab. Is this 
happy exemption from such an accident the result of care in selecting 
the virus, or does it depend on our constant use of the dried scab ? Is 
not the danger of having blood intermixed with the lymph much greater, 
when the vesicle is opened by the surgeon on the eighth day, than when 
the lymph is left to dry and form a scab in the natural mode? 

Operation. — Under this head we shall consider several important 



814 VACCINE DISEASE. 

points: the relative value of the dried scab and fresh lymph ; the ques- 
tion as to whether it is best to raise more than one vesicle by more 
than one insertion of the virus; and the various modes of performing 
the operation. 

In this city it has been the custom for many years past to use the 
dried scab, and to raise^ as a rule, but one vesicle. After an experience, 
extending, in the case of one of us, over thirty-two years, during which 
we have never used anything but the crust, and have rarely made more 
than one insertion, we can aver that we have never known any one to 
die of small-pox who had been successfully vaccinated and then suc- 
cessfully revaccinated by this method. We have seen a good many 
mild varioloids, in subjects that had not been revaccinated, from the 
ages of twelve and fifteen upwards, but only in two cases have we 
known the disease to be severe enough to pock-mark the patient. ^Ye 
know of but one death from small-pox in our own circle of patients. 
This occurred in a gentleman 43 years of age, who was originally vac- 
cinated by the late Dr. C. D. Meigs, and who was never revaccinated 
until four or five days after he had been exposed directly to the small- 
pox infection. The operation came too late. Though the puncture 
took^ he died of hemorrhagic small-pox of a virulent form. 

In using the crust we have always taken great care to select only 
those from the most healthy children. Any blemish upon the skin, 
any shadow of doubt as to the perfection of the vaccine disease, ought 
always to cause the rejection of the crust. 

In our remarks upon the possibility of the conveyance of the syphil- 
itic poison by vaccination, we cited Mr. Hutchinson's opinion that the 
agent of communication is the blood of the vaccinifer, and not the 
lymph of the vaccine vesicle. We have never known a case of such 
conveyance in our own practice, nor in that of our various medical 
friends in this city. Can this exemption depend upon the use of the 
dried lymph, whereby the chance of having blood intermixed with the 
lymph is lessened ? 

The scab is less certain to take the first time than the fresh lymph, 
but it can always be made to take by perseverance, and we confess 
that it is hard for us to understand why the vaccine disease, if it be 
perfect in all its stages and phenomena, is not as much a vaccine dis- 
ease when it springs from the crust as when it proceeds from fresh 
lymph, and therefore as competent to aifect the economy through 
which it passes according to its natural law. 

If the crust is to be used, it ought to be as fresh as possible, to insure 
its taking at the first operation. When the physician is obliged to keep 
it for several weeks, he should preserve it in some close receptacle, as 
between glasses, in tin-foil, oiled paper, between two pieces of wax, or 
in hermetically closed glass vials. 

If the fresh Ij^mph is preferred, the children to be vaccinated should 
be collected together about the vaccinifer (the child from whom it is to 
be taken) on the eighth day of the disease. The vesicle must be very 
carefully opened, so as to avoid wounding the true derm, and thereby 



OPERATION. 815 

causing any effusion of blood, and the lymph conve^^ed on a lancet di- 
rectly from arm to arm. 

It is proper to say that this is the mode of vaccinating usually pre- 
ferred in Europe as the most certain and successful. 

Though we have stated that, in our own practice in this city, one 
thoroughly characteristic vesicle at the primary vaccination, and one 
again at the revaccination, has been entirely successful in securing com- 
j)lete protection against small-pox, the opinion is held abroad that more 
than one vesicle gives greater security, in the event of small-pox attack- 
ing the vaccinated, than a single one. This opinion, which is based upon 
very numerous observations in England and Germany, is so strong and 
positive that we think it best to advise hereafter that at least two in- 
sertions, so as to raise two vesicles, shall be made in this country. 
Any one who wishes to study this question may refer to an excellent 
article on Vaccination, by Dr. Edward Cator Seaton, in Reynolds's System 
of Medicine, vol. i, page 483, where the whole subject is fully discussed. 
At page 499 Dr. Seaton insists that it is the duty of the physician to 
produce four or five genuine, good-sized vesicles.^ 

It is proper to put before the reader this opinion of so able an au- 
thority as Dr. Seaton, so that any one who feels bound by such author- 
ity may follow his rule. For ourselves, we can only repeat that thus 
far in our own experience, one thoroughly good primary vaccination, 
and a second characteristic vesicle obtained at the revaccination, have 
been entirely successful and sufficient. In obedience, however, to the 
facts collected in England and Germany, we shall hereafter, as stated 
above, advise the raising of at least two good vesicles at each vaccina- 
tion. It makes but little difference whether the two be raised on one 
arm, or one on each. For the convenience of handling the child, we 
think it will be best to make the two insertions on one arm. 

We think it the duty of the physician who vaccinates a child always 

1 The protective power of vaccination, as well as the influence exerted by the per- 
fection and the number of the insertions, as shown by the cicatrices, is remarkably 
well exhibited in the following table quoted by Dr. Seaton (Art. Vaccination, in Rey- 
nolds's Syst. of Med., vol, 1, p. 499), from Mr. Marson. The table is based upon 
15,000 cases. Of these it was found that the unvaccinated died at the rate of 37 per 
cent., and the vaccinated at the rate of only G^ per cent. 

Classification of Patients Number of Deaths, per cent, 

affected with Small-pox. in each class respectively. 

1. Unvaccinated, 37. 



o 



Stated to have been vaccinated, but having no cicatrix, . . 23.57 

3. Vaccinated. 

a. Having one vaccine cicatrix, . . . . .7.73 

h. Having two vaccine cicatrices, . . . . .4.70 

c. Having three " " 1,95 

d. Having four or more vaccine cicatrices, . . .0.55 

a. Having well-marked cicatrices, ..... 2.52 
^. Having badly-marked " 8.82 

4. Having previously had small-pox, 19. 



816 VACCINE DISEASE. 

to see to it himself that the result is a perfect vaccine disease. This 
matter is too important to be trusted to any inexperienced person. The 
physician has not done his duty who trusts to anything but his own 
eye as to the genuineness of the vesicle w^hich results from his opera- 
tion. He should examine it himself on the eighth or ninth day of the 
disease. The special characters of the disease have already been fully 
described. 

It would be well, too, that physicians in charge of families should 
examine the cicatrices which follow vaccination, and if they fail to pre- 
sent the characters which belong to successful operations, he ought to 
repeat the vaccination. Dr. Welch, whose experience in this matter 
was large, says that a good cicatrix is one "with a well-defined mar- 
gin, slightly excavated, and reticulated or honeycombed." What he 
classifies as a fair cicatrix presents the same characteristics, but to a 
less marked degree, and poor ones are those "pointed out as the result 
of vaccination, but which are so indistinct or uncharacteristic as to 
make it difficult, and sometimes even impossible, to recognize them as 
vaccine scars." In case any practitioner should meet with the latter 
in a family he may be attending, he ought, we think, to urge upon the 
parents the necessity of repeating the operation at once. 

Eevaccination. — We think few physicians or laymen who watched 
the violent epidemic of small-pox which prevailed in this city during 
1871 and 1872, can doubt as to the necessity of revaccination. So con- 
vinced are we by what we saw during that epidemic of this necessity, 
that we shall, hereafter, advocate the repetition of the operation at the 
age of puberty as a matter of domestic habit and law, a matter to be 
attended to by the heads of families with the same regularity and care 
that is now universally bestowed by all educated and careful people 
upon the vaccination of infants. Each child of a family ought to be 
subjected to this operation at or about the age of fifteen, and we think 
the family phj^sician ought to bestow the same care upon this as upon 
the primary vaccination. One trial, without result, we hold to be of 
no more use than it would be in an unvaccinated child. The trial should 
be made again and again until a result is obtained. We have ourselves 
of late years repeated it twice, three times, and, in one instance, seven 
times, before we succeeded in obtaining a vesicle. Once the vesicle 
obtained, with a good areola, we believe the subject is safe for many 
years, probably for the lifetime. 

The characters of the vaccine disease produced by a revaccination 
are not alwaj^s the same as those obtained at the primary vaccination, 
especially when the time between the two operations is only that ex- 
tending from birth to puberty. We have seen at later periods of life, 
at thirty and forty years of age, for instance, as perfect specimens of 
the vaccine disease from a secondary vaccination as we have ever seen 
in the infant. Not a feature has been wanting. The exact phases of 
the disease, the papule, the vesicle, the precise duration as to time, the 
areola, the constitutional disturbance, and the resulting cicatrix, have 
all been perfect in every point. 



REYACCINATION. 817 

It is difficult to escape the conviction that in such cases as these just 
mentioned the protective power of the primary vaccination had been 
entirely obliterated, and such, indeed, is and has been the oj^inion of 
many. A careful observation has shown, however, that this is not 
correct, and that, to use the words of Dr. Seaton {loc. cit., p. 511), we 
cannot ''draw from the local phenomena of revaccination any infer- 
ences whatever as to the state in which the revaccinated person was 
as to liability to small-pox. Jenner himself, indeed, pointed this out in 
his first treatise, and showed that the natural cow-pox might be in- 
duced again and again in persons who, being protected against variola 
by their first attack of cow pox, could not be variolated either by inoc- 
ulation or by exposure, as well as that cow-pox might be made to take 
on those who had had small-pox." A table, given by Dr. Seaton to 
show the results of revaccination in the Wtirtemburg army in 1831-35, 
and in the English array in 1861, shows conclusively that revaccination 
Avas nearly as successful in producing a perfect vaccine disease in those 
who bore the marks of previous small-pox, and in those who had good 
cicatrices of previous vaccinations, as in those who bore no marks of 
previous vaccination or small-pox. 

These facts overthrow the prevalent notion held by the public at 
large and by many physicians, that a successful revaccination is a sure 
sign that the subject had lost the protection aff'ordcd by the previous 
vaccination. They also overthrow the idea that it is necessary to re- 
vaccinate every few years in order to renew the protective power of 
the vaccine disease. One good primary vaccination doubtless affords 
full protection throughout life in many, but it does not in all, and since 
it is impossible to determine which are the protected and which the 
unprotected, it is necessary to revaccinatc all. But one successful re- 
vaccination is probably all that is required. Should, however, any one 
wiio has been thus successfully revaccinated be exposed directly to the 
infection of small-pox many years afterwards, it might be well to repeat 
the operation once again. The fashion, however, of being revaccinated 
every few years, which some persons indulge in and some physicians 
assent to only too readily, is simply a work of foolish supererogation 
not unattended with risk, since vaccine punctures, though made in the 
most legitimate way, will occasionally cause severe and even danger- 
ous sores. 

We have already said that revaccination at puberty rarely produces 
a vaccine disease of typical character. Still more is this true of chil- 
dren under puberty. At that early age the disease usually begins ear- 
lier after the puncture than in the primary form, reaches its height by 
the fifth or sixth day, and then declines. The vesicle is apt to be acu- 
minated rather than umbilicated, the areola is irregular in outline, nar- 
rower, paler, and is usually hard. The scab is small and imperfect, 
looking more like one formed by the desiccation of pus than like that 
formed from true vaccine Ij^mph, and it is often complete by the eighth 
day, and soon falls. There is often a good deal of constitutional irrita- 
tion caused by revaccination, more even than in the primary disease, 

52 



818 VACCINE DISEASE. 

and there is also much local irritation in the form of itching and pain. 
Nevertheless, these appearances are invaluable as showing that the 
lymph employed has affected the constitution of the patient. Without 
some such response to the revaccination, we hold the operation to have 
been useless, and always repeat it, as has already been stated. 

To impress upon all the power and value of revaccination, we will 
quote some facts given by Dr. Seaton (loc. cif., p. 509): "Heine found 
that in five years there occurred among 14,384 revaccinated soldiers in 
Wtirtemburg only one instance of varioloid, and in 30,000 revaccinated 
persons in civil practice only two cases of varioloid, though during these 
years srnall-pox had prevailed in 344 localities, producing 1674 cases of 
modified and unmodified small-pox among the not revaccinated, and in 
part not vaccinated, population of 363,298 persons in those places in 
which it had prevailed. In the Prussian army, since the introduction 
of systematic revaccination of all, the annual deaths from small-pox 
(which at one time were 104) have not averaged more than 2 j and on 
analysis of 40 fatal cases that occurred in twenty years, it appeared 
that only 4 were in persons who were said to have been successfully 
revaccinated." 

He also cites Mr. Marson's statement to the effect that in '- thirty 
years no nurse or servant at the Small-pox Hospital has taken small- 
pox, he having taken care always to revaccinate them on their coming 
to live in the hospital; and further, that when a large number of work- 
people were employed for several months about the hospital, most of 
whom consented to be revaccinated, two only were attacked by small- 
pox, but they were amongst the few who were not revaccinated." 

With a few words on the mode of performing the operation of vacci- 
nation, we shall bring this article to a close. 

Different methods of inserting the vaccine virus have been emploj^ed 
by different practitioners. The two methods most frequently resorted 
to are those by incision and puncture. The former consists in making 
a superficial incision of several lines in length into the skin, in such a 
way as to cause a very slight effusion of blood. Into this is introduced 
a small quantity of a dried vaccine scab reduced to a fine powder, or a 
piece of fine thread wet with the vaccine fluid or with water holding 
in suspension a portion of dried virus. Over the wound is then placed 
a piece of isinglass plaster, which is secured by a bandage. This is to 
be removed after two or three days, and the disease allowed to pursue 
its regular course. The operation by puncture is performed by intro- 
ducing horizontally beneath the skin a needle or lancet charged with 
the virus, and then withdrawing it in such a way as to leave the virus 
in the wound. Of these two modes the latter is the one now most fre- 
quently adopted, the former having been found to occasion, not unfre- 
quently, a spurious disease, and to be of very diflicult application in the 
cases of children. For our own part we have used for some years 
past a method that we have found much the most convenient in chil- 
dren, and which rarely fails when it is carefully performed. We take 
a common thumb lancet, w^hich should not be too sharp. Holding the 



VARICELLA. 819 

arm of the child with our left hand, and stretching the skin between 
the forefinger and thumb, whilst the under part of the arm is grasped 
by the second finger placed beneath the first, we lay the lancet flat 
upon the skin, and using the point, remove, by a repeated and very 
ii:entle rubbing movement, the cuticle, until the surface of the derm is 
laid bare, so as to allow of a perceptible, and merely perceptible oozing 
of blood, or, in other words, so as to expose a living surface. This sur- 
face should be about as large as a small-sized bird-shot, and it should 
not bleed, but merely show that the vascular part of the derm has been 
reached and slightly exposed. On this surface the vaccine fluid or dis- 
solved scab is to be placed in quantity sufficient to cover it, and the 
nurse should be told to leave the arm bare and untouched for twenty 
minutes, or until the applied fluid has dried into a little scab, when no 
further precautions are necessary. This mode of operating may at first 
seem tedious and painful. We can only say that when performed 
gently and gradually", it causes so little pain that we have often prac- 
tised it upon sleeping children without waking them. 

The place usually selected for the operation is, as every one knows, 
on the arm, close to the insertion of the deltoid muscle. This is the 
best place as a general rule, and particularly in girls, whose parents 
often object to having the insertion made below this, lest the scar 
should be visible in after years, when the arm is uncovered. In boys 
we often select the radial edge of the forearm some two inches below 
the elbow, since in this place the pock is least apt to be injured in the 
act of dressing the child, or of lifting it about. 



AETICLE IX. 



VARICELLA. 



Definition; Synonyms; Forms. — Yaricella is a contagious eruptive 
disease of benign nature, characterized by more or less numerous trans- 
parent vesicles following rapidly upon small red elevations. The erup- 
tion is usually preceded by slight initial symptoms lasting from one to 
two days, and it terminates by the desiccation of the vesicles about the 
fifth or eighth day after their appearance. 

It is known also in English by the names of chicken-pox, swine-pox, 
and crystalli. 

Several different forms of the disease have been described by different 
writers under the titles of lenticular, conoidal, and globular ; but inas- 
much as these varieties are of no real importance in practice, we shall 
merely advert to them casually in our account of the eruption. 

Causes. — Yaricella is propagated in two ways; by contagion, and by 
epidemic influence. That it is contagious there can be no doubt, since 



820 VARICELLA. 

nearly all observers agree upon this point. In our own experience we 
have seldom kiiown any child, who had not had the disorder previously, 
to escape it when once it has entered a household. It rarely attacks 
an}^ but children. Its epidemic nature is shown by the fact that in 
some seasons it is scarcely seen, whilst in others it prevails extensively 
over large districts of country, and attacks many children in the great 
towns and cities of those districts. Varicella occurs only once in the 
same individual. 

Considerable discussion has taken place at various times as to the 
real nature of varicella, some asserting that the disorder is merely one 
of the varieties of modified small-pox, while others maintain as strenu- 
ously that it is an independent and specific disease. The weight of 
authority, however, seems to be clearly in favor of the last-mentioned 
opinion, and we have no hesitation in avowing this to be the conclusion 
to which our own reading and experience have brought us. When we 
consider, indeed, that varicella is, unlike either variola or varioloid, in- 
communicable by inoculation, that it attacks indifferently the vaccin- 
ated and unvaccinated, that its course is entirely unaffected by previous 
vaccination, and that the vaccine disease is readily taken, and passes 
through its regular phases after varicella, we do not see how we can 
refuse to believe that the latter is something entirely independent of 
small-pox, and therefore a distinct and peculiar malady. 

Symptoms; Course; Duration. — The eruption is usually, but not 
alwaj'S i)receded by prodromic symptoms. These seldom last more 
than one, or at most two days, and consist at the very beginning of 
slight chilliness, or of a chill even, which is followed by a more or less 
marked febrile reaction. In some instances there is vomiting, but this 
is rare, and when it does occur, slight. When fever exists it is marked 
by headache, accelerated pulse, slight warmth of the surface, pain in 
the back and limbs, languor, indisposition to play, some unusual irrita- 
bility of temper, diminution or loss of appetite, and unusual thirst. 
These symptoms may be present, and yet in so mild a shape that the 
child shall show no disposition to abandon its ordinary habits of activity 
and play, while in other cases again, there are literally no initiatory 
symptoms whatever, and the appearance of the eruption is the first 
declaration of the presence of the malad3\ Even when constitutional 
sjnnptoms are present, thej^ usually disappear by the third day. 

The eruption appears in the form of small papular spots, of a deep 
red color, and irregularly circular shape, w^hich generally show them- 
selves first on the front and back of the trunk, and extend very soon to 
the fiice, and a little later, to the extremities. We have known a child 
to go to bed at night with slight headache and fever, and present a 
well marked though not j^et abundant varicellous rash upon the upper 
part of the trunk, and on the face, on the following morning. These 
papules exhibit, in the course of a very few hours^ small vesicles in 
their centres; indeed, according to some observers, the eruption is 
vesicular from the very beginning. On the second day the papules are 
in great measure converted into vesicles, which may be either small 



DIAGNOSIS — PROGNOSIS — TREATMENT. 821 

and acuminated, constituting the lenticular form of the disease, or they 
may be larger and of a more globular shape, constituting the conoidal 
and globular or globose forms of Willan and Bateman. We deem it 
unnecessary, as above stated, to describe different varieties of varicella, 
since this is useless for any practical purposes, and because we constantly 
see upon the same subject vesicles of very different shape and size. 
When fully completed, the vesicles are often of very considerable size — 
two or three lines in diameter; they contain a transparent fluid, 
which is either entirely colorless or of a faint orange tint, and some of 
them are surrounded by a small ring of inflammation. On the third 
day, the eruption continues in nearly the same state as on the second, 
except that the fluid contained within the vesicles assumes a yellowish 
appearance, owing to its passage from the serous into the purulent con- 
dition. On the fourth day/ the process of desiccation begins and goes 
on rapidl}', the vesicles that have not been broken by accident, or torn 
by the fingers of the child in its efforts to appease the itching which 
they give rise to, assuming a shrivelled and shrunken appearance at 
their margins. As this process goes on, the vesicles are gradually con- 
verted into light brownish scabs, so that by the sixth day they are 
nearly all dried np. The scabs are usually thin; they dry from the 
circur^jference to the centre, and between the eighth and ninth days fall 
off, leaving behind faint red spots, not depressed below the general sur- 
face, and which soon disappear. 

The eruption is generally accompanied, as was stated above, by a 
sensation of heat and itching in the vesicles, which causes the child to 
rub and scratch them in such a way as often to break those which he 
can reach, and thus prevent them from passing through the regular 
periods of maturation and desiccation. 

Diagnosis. — There is but one disease with which varicella could be 
confounded, and that is variola in some of its shapes. With regular 
small-pox such a mistake could scarcely happen even to the inexperi- 
enced. With varioloid, on the contrary, there might be some difficulty, 
and yet, if it is borne in mind that in varioloid the initiatory fever is 
much more severe, lasting three days instead of twelve or thirty-six 
hours, that the eruption appears first on the face and extends very 
slowly to the trunk and extremities, and that the conversion from the 
papular into the vesicular condition is much more gradual than in 
chicken-pox, we think no serious difficulty can ever occur in making 
the distinction between the two affections. 

Prognosis. — The prognosis is always favorable. The only real 
trouble that we have ever known to occur has been from catarrh or 
pneumonia contracted by imprudent exposure during the convalescence. 

Treatment. — In a large majority of the cases, varicella requires no 
treatment beyond attention to diet for the first two or three days, and 
the avoidance of cold during the convalescence. AYhen the constitu- 
tional symptoms are marked, the fever and headache being consider- 
able, a dose of some mild cathartic, a little sweet spirit of nitre in cold 



822 TYPHOID FEVER. 

lemonade or orangeade, rest in bed, and one or two foot-baths, will be 
all that is necessary to reduce these symptoms and make the patient 
comfortable. 



AETICLE X. 



TYPHOID FEYER. 



It is only of late years that the frequent occurrence of typhoid fever 
in young children has been fully recognized by medical authors. From 
the date of the publication of the classical work of Louis on this disease, 
until the year 1839, it appears to have been the almost universal belief 
that it was an affection limited to adult'life; and with the exception of 
a few brief and vague descriptions, which evidently referred to this 
disease, though other names were used to designate it, medical litera- 
ture contained no account of typhoid fever as it occurs in childhood. 
In the latter part of 1839, however, Eilliet (^These de la Faculte, 1810; 
and Maladies des Enfanis, t. ii, pp. 663-739) and Taupin {Journal des 
Connaissances Med.-Chirurgicales) published separate and independent 
memoirs on this subject; and since that time the occurrence of ty- 
phoid fever in children has been frequently observed and very carefully 
studied. 

The fact that it was so long overlooked, is undoubtedly to be ex- 
plained, in great part, by certain peculiarities which the disease pre- 
sents in children, which caused its real nature to be mistaken, and led 
to the application of other names. 

Of these names, that of infantile remittent fever was the most fre- 
quently used, and though this term was made to include a number of 
other diseases, and although remittent fever does occur in children, 
there can now be no doubt that a large proportion of the cases so 
styled, were in reality cases of typhoid fever. 

Causes. — Age. — Typhoid fever has been observed during the first 
year of life, but is rare under the age of two years. "We have however 
met with well-marked instances of it at the age of eighteen or twenty 
months. It is comparatively frequent between the ages of three and 
eight years, and it attains its maximum of frequency in childhood be- 
tween the ages of eight and eleven years. 

Sex. — The statistics of most authorities show a preponderance, more 
or less marked, of cases occurring in boys. In some series of cases this 
disparity has been remarkable (three to one) ; but, notwithstanding, it 
is probable that in a very extensive series the difference would be com- 
paratively trifling. 

Contagion. — It can scarcely be doubted that typhoid fever is occasion- 
ally transmitted by contagion, but the degree of its contagiousness is 
extremely slight. On the other hand, it is subject both to epidemic 



ANATOMICAL APPEARANCES. 823 

and endemic influences in a marked degree; and it is owing to the 
varying action of these causes that it presents the wide variet}^ in type 
and severity, which will be described. 

Anatomical Appearances. — These are strictly analogous to those 
found in the adult. When death occurs early in the attack, the agmi- 
nate glands of the ileum are found swollen, prominent, injected; the 
alteration being most marked in those nearest to the ileo-eoecal valve. 
Later, however, these glands ulcerate, the softening beginning either 
on the surface, and extending more and more deeply, or beginning in 
the deeper portion of the patch, so that the superficial layer may be 
thrown off as a slough. 

These ulcers thus destro}" the mucous membrane, and present the 
submucous or muscular coats for their base; or, in some instances, the 
ulcerative process may extend through the aiuscular and even through 
the peritoneal coats. 

According to JRilliet (loc. c^Y.), however, these ulcers are more slow in 
forming, smaller, and less numerous and deep in children than in adults; 
and, indeed, he believes that in not a few instances the swelling and in- 
flammation of the gland may undergo resolution without the occurrence 
of ulceration. 

Too much importance must not, however, be attached to this state- 
ment, since it appears to us evident that a few cases, at least, of typhus 
fever are included amongst those upon which his memoir is based. 

The solitary glands are, in the early stage of the disease, prominent, 
and may be distended with a serous or more thick and yellowish secre- 
tion, so as to resemble vesicles or even pustules. Later in the attack 
their mucous covering is destroyed, and small, round, or oval ulcers, 
with everted edges, remain. These ulcers are also most numerous in 
the lower part of the ileum, though in some cases they are met with 
quite abundantly in the large intestine. 

The mesenteric glands are enlarged, softened, and strongly injected, 
the change corresponding in intensity to that of the agminate glands 
in the ileum, and being most marked in those glands which are nearest 
the ileo-coecal valve. Usually the swelling of these glands subsides 
without suppuration occurring, but occasionally this ensues, and the 
gland is converted into an abscess with thin walls. 

The cicatrization of the intestinal ulcers appears usually to occur 
rapidly; thus, Rilliet has seen the process completed by the thirtieth 
day, though this is probably sooner than it is entirely finished in the 
majority of cases. 

Ulcers of other mucous surfaces, as of the pharynx and larynx, are 
more rarely met with in children than in adults. The spleen is nearly 
always considerably enlarged and softened. 

The blood in severe cases is dark and uncoagulable, and the linino- 
membrane of the heart and large vessels is stained by imbibition. In 
some cases quite firm coagula are met with in the cavities of the heart. 

Even in cases where the most violent nervous s^^mptoms have been 
present, the brain rarelj^ presents any more positive lesion than mere 



824 TYPHOID FEVER. 

congestion of the vessels of its membranes and substance, with at 
times some subarachnoid effusion. Of course, in cases where death has 
resulted in consequence of some complication, the lesions of the inter- 
current disease will be found. 

Symptoms. — The general course of typhoid fever is much the same in 
children as in adults. 

It presents also the same wide variety in its type and degree of se- 
verity, depending upon the predominance and excessive development 
of some one of the elements of the disease; and it would be easy, there- 
fore, to divide the disease into a great number of forms, according to 
the prominence of each functional disturbance; but as our object is 
merely to give a practical description of the disease as met wnth in 
children, we will, in considering its course, give a brief sketch of an 
ordinary case, and then dwell in detail upon certain symptoms which 
require special notice, as presenting special peculiarities in childhood. 

In the majority of cases, the attack is preceded for some da^^s by 
slight prodromes; the child, who ordinarily may enjoy robust health, 
appears languid, and is easily tired, and indisposed to play ; he loses 
his appetite, is restless during sleep, and possibly may complain of 
colicky pain in the abdomen, perhaps attended with slight looseness of 
the bowels. After this state of vague indisposition has lasted from 
three or four to eight or ten days, more decided symptoms manifest 
themselves, and the attack may be said to fairly begin. 

More or less febrile action now appears; but this is rarely continuous, 
and for the ensuing five or six days there are distinct and marked re- 
missions, usually in the morning, but sometimes so marked and pro- 
longed that it is only towards night that the skin becomes heated, the 
pulse frequent, and the child grows restless, while, during the day, he 
has merely appeared somewhat dull and languid. The loss of appetite 
continues, and becomes more complete, though thirst is marked ; vom- 
iting is apt to follow eating, and is sometimes frequent and spontane- 
ous; the tongue presents a moist, whitish-yellow fur in the centre. 
The bowels either continue loose, or now become so for the first time; 
the abdomen becomes somewhat large and tympanitic, and slight ten- 
derness may be present in the right iliac region towards the close of 
the first week. 

The strength is rapidly lost, and the child, after the first few days, 
shows no desire to leave the bed. The respirations are somewhat 
hurried, and are often accompanied by sonorous rales and slight dry 
cough. The pulse is accelerated, but rarely rises at this stage above 
110. 

The expression grows dull and listless, unless temporarily excited 
during delirium, and the child takes but little notice of surrounding 
persons or objects. During the night there may even now be a tend- 
ency to more marked cerebral disturbance, and the little patient grows 
very restless, utters sharp, shrill cries, or talks unmeaningly. 

About the end of the first week the characteristic eruption appears, 
first on the upper part of the abdomen, in the form of small, oval spots, 



SYMPTOMS. 825 

scarcely, if at all, elevated above the surfiice, of a light rose color, dis- 
appearing on very slight pressure, and quite rapidly returning. 

During the second week, the symptoms become more severe. The 
fever is more continuous, and the temperature ranges in different cases 
from 102° to 105°; it may still present, however, decided morning re- 
missions, and it is not rare for profuse warm perspiration to occur, with- 
out having any critical value whatever. The pulse becomes more fre- 
quent, 120, 140, even 160, and at the same time smaller and of less force. 
The respirations are also more hurried, and, when the pulmonary com- 
plication is marked, may be very rapid and shallow, and the cough fre- 
quent and annoj'ing; in such cases, auscultation reveals, especially over 
the postero-inferior part of the lungs, abundant mucous, or subcrepitant 
rales. The vomiting ceases, and the child will usually take the liquid 
food offered it; the tongue becomes more heavily furred, and may be 
drv and brownish in the centre, thouo-h it often remains moist and yel- 
lowish-white throughout. Thirst is apt to diminish, owing to dulness 
of the perceptions, but the child will frequently drink greedily of cold 
water if offered to it. The diarrhoea persists, however, and the stools 
are ochre yellow and fluid ; the bellj^ is more tympanitic, and may be 
extremely distended. The discharges, both of urine and fseces, are often 
involuntary, and the child does not even appear conscious of them. 
The urine is high-colored and scanty. The eruption continues and be- 
I comes more abundant, the spots which appeared passing away and 
being followed by successive crops. Sudamina are also frequently pres- 
ent, especially when sweating occurs. The mind becomes more and 
Imore dull, though it is nearly always possible to rouse the child by 
speaking loudly to it; delirium is usually present, especially in the 
night, and manifests itself in young children by restlessness, sharp, un- 
meaning cries, and a wild expression of the face, and in older ones by 
muttering, or even by attempts to leave the bed. Irregular muscular 
movements, such as floccitatio and subsultus, are rarely noticed ; though 
at times these, and even spasmodic rigidity of the trunk or limbs, or 
convulsions, may be present. 

We have thus sketched the course of what is, perhaps, the most com- 
mon form of typhoid fever in children, w^here the disease begins gradu- 
ally, and either remains mild throughout, or assumes a more grave 
character during the second week. 

In a certain number of cases, however, the onset of the disease is far 
more sudden and violent, and the severity of the attack is manifested 
from its earliest period. In this form, the prodromes are brief, or almost 
entirely absent ; and there may be in older children an initial chill, or 
the only symptoms present are marked debility, languor, and drowsi- 
ness. Daring even the first two or three days, however, there is apt 
also to be frequent vomiting, severe headache, or marked hebetude, and 
high fever, which usually presents the same marked morning remis- 
sions and evening exacerbations as in the milder form. The sleep is 
restless and disturbed, and the child either utters sharp cries, or, if older, 
talks incoherently. The pulse and respiration arc much accelerated, 



826 TYPHOID FEVER. 

and the temperature of the surftiee rapidly rises, till, by the end of the 
first week, it may reach 103° or 105°. The cerebral disturbance may 
mask the presence of any abdominal pain ; and as it is not unusual for 
the bowels to be quiet for the first few days, the case may closelj^ sim- 
ulate some acute cerebral disorder. By the end of the first week the 
disease is developed in its full severit}^ The fever is more nearly con- 
tinuous, the morning remissions being comparatively slight, and the 
skin remains constantly dry and hot. There is deep stupor, from which 
the child is roused only with much difficulty, and which occasionally 
alternates at night with restlessness, jactitation, and noisy delirium. 
The pulse is very frequent and feeble, and the breathing accelerated^ 
and usually accompanied with bronchial rales. The vomiting ceases, 
but the abdomen becomes tympanitic, and there is more or less abun- 
dant diarrhoea; the stools are often passed quite involuntarily, and the 
urine is either retained or dribbles away unconsciously. Epistaxis oc- 
curs in a large proportion of cases, and about this time the character- 
istic rose-colored eruption makes its appearance. During the second 
week, all of the symptoms become more grave, and the patient may suc- 
cumb to the violence of the disease, or remain for a week or ten daj^s 
plunged in profound stupor, with subsultus and marked muscular tre- 
mor; with the lips and teeth coated with sordes, the tongue tremu- 
lous, dry, and coated with brown crusts, the abdomen tympanitic, and 
the stools frequent, thin, and passed involuntarily; with the pulse run- 
ning, feeble, from 130 to 160 in the minute; the respirations shallow, 
imperfect, and attended with subcrepitant rales, indicating passive con- 
gestion of the lungs; with the urine retained, dark-colored, and even 
albuminous; and yet gradually emerge from this apparently hopeless 
condition to enter upon convalescence about the close of the third 
week. 

In favorable cases, between the fifteenth and twenty-first day, the 
grave symptoms begin to abate. The child's expression becomes more 
natural, and often the earliest sign of approaching convalescence will 
be the aj^pearance of a smile of recognition, or of pleasure at the con- 
sciousness of improvement. The fur upon the tongue becomes looser, 
moister, and begins to separate, and the appetite slowly returns; the 
distension of the abdomen diminishes, and the stools are again passed 
consciousl}^ and voluntarily, and gradually assume a healthy appearance. 
Eestlessness and delirium disappear, and the sleep becomes quiet and 
refreshing; the fever subsides, and the temperature falls, and again 
shows a marked difference between the morning and evening. The 
child thus passes into a state of convalescence, which, when not dis- 
turbed by complications, is quite rapid, though attended with marked 
emaciation, extreme debility, and feebleness of digestive power, with a 
tendency to intestinal disturbances. In some rare cases, at times with- 
out assignable cause, at others from improper exposure or exertion, or 
indiscretions in diet, the patient suff'ers a relapse, the original symp- 
toms reappear, and a second fully developed attack of typhoid fever, 



SPECIAL SYMPTOMS. 827 

attended with marked nervous symptoms, characteristic eruption, and 
diarrhoea, may ensue. 

In very severe eases, on the contrary, and especially when a fatal re- 
sult is to follow, the condition of the patient grows more and more 
grave after the end of the second week, unless, as at times happens, 
death has occurred sooner from the violence or malignancy of the at- 
tack. The nervous symptoms become more marked, and the child sinks 
into a deeper stupor, even approaching true coma, or the stupor is in- 
terrupted by violent agitation, with cries or efforts to leave the bed, 
or by muscular twitchings, picking at the bed-clothes, or even general 
convulsions. The pulse is \evy rapid and small ', the respirations hur- 
ried and noisy, and physical examination frequently reveals the exist- 
ence of extensive bronchitis or hypostatic pneumonia. Vomiting is 
rarely present, but hiccup may be frequent and distressing; the belly 
is enormously distended, the stools frequent, involuntarj", and at times 
blood}'. Bed-sores form on points subjected to pressure, and death en- 
sues amid jorofound stupor and with signs of extreme pulmonary ob- 
struction. 

At other times death occurs not so much from the extreme violence 
of the disease itself as from the development of some one of the com- 
plications which will be mentioned hereafter. 

Special Symptoms. — Although, as has been seen, the general course 
of typhoid fever is much the same in children as in adults, there are a 
few symptoms which require more detailed notice, as presenting pecu- 
liarities which im2)ress special features upon the disease as it occurs in 
childhood. 

Frodromes. — In children, as in adults, typhoid fever is nearly always 
preceded by a marked prodromic stage, and the passage from the state 
of health to the fully developed disease is usually very gradual. The 
duration of these prodromes varies from three or four to ten days, being 
least in the more severe cases. 

Fever. — Condition of Skin. — "VVe have already remarked that, in the 
early stage, there are apt to be very marked remissions in the febrile 
action, lasting even throughout a considerable part of the day; the 
exacerbations of the fever usually occurring towards evening. West 
states that in some few instances two distinct remissions and exacer- 
bations may be noticed in the course of every twenty-four hours. It 
is this feature which gained for the disease the name of infantile remit- 
tent fever, and caused it to be ranked formerly with the malarial diseases. 
Towards the middle of the second week, however, the remissions become 
much less marked; the temperature, which in some cases reaches 104:° 
or 105°, merely presenting a somewhat marked fall in the morning. 
The skin is hot and dry as a general rule, but sweats are more apt to 
occur during the height of the disease than they are in adults; they 
are not, however, of any prognostic value. 

Digestive Symptoms. — Among the earliest and most important symp- 
toms are various disturbances of the digestive functions. The appetite 
rapidly fails, and is often lost before the attack fairlj^ begins. Thirst 



828 TYPHOID FEVER. 

is, however, marked until dulness of the mind appears, after which it 
also may be entirelj^ absent, though the child will usually drink if cold 
water be offered to it. The tongue is alvvays furred, usually being cov- 
ered throughout the course of the disease by a thick yellowish-white 
coat, which may remain moist and loose, or, in very grave cases, be- 
come dry and brownish. Sordes are not often observed. Vomiting, 
which is perhaps not more frequently met with in the early stage in 
children than in adults, may be very frequent and persist until far into 
the second week. In the majority of cases, diarrhoea is either present 
or the bowels are peculiarly sensitive to the action of laxatives. In 
some cases, however, and especially those where vomiting is marked, 
constipation of a quite obstinate form is present. The conjunction of 
these two s^-mptoms, in connection with the cerebral symptoms present, 
may cause the case to strongly resemble the first stage of tuberculous 
meningitis; the doubt may, however, be usually resolved by careful 
examination, as will be more fully alluded to under the head of diag- 
nosis. 

The stools, when diarrhoea exists, are ochre-colored, fluid, and, on 
standing, deposit a sediment of shreds of mucous membrane, epithelium, 
and partially digested food. Mucus is rarely present; but blood, in 
varying amount, may be mixed with the fecal matter. When the 
amount is large, it is usually due to the ulcerative process in the intes- 
tine having opened a vessel of considerable size, and then constitutes a 
very grave complication. 

In 3^oung children it is difficult to establish the existence of abdomi- 
nal pain, but, when they are capable of describing their sensations, col- 
icky pain is frequently complained of in the early stages; and even in 
the youngest children, pressure in the right iliac region may often be 
seen to be painful. 

Tympany is usually present at some time during the attack, espe- 
cially when there is diarrhoea. Even when the bowels are confined, 
however, the abdomen is never retracted. Eilliet states that, in some 
grave cases, he observed such great tympany that the abdominal walls 
were thin enough to allow the outlines of the convolutions of the in- 
testine to be clearly seen. 

Enlargement of the sj^leen nearly always exists, but frequently to so 
slight a degree that it cannot be readily detected either by palpation or 
percussion, and even when considerably enlarged, it is aj)t to be entirely 
hidden by the distension of the abdomen. 

The urine presents the ordinary febrile conditions, being scanty, high- 
colored and of high specific gravity; the pigment is increased, and the 
chlorides much diminished. 

The stools are, as we have already said, often involuntary during the 
height of grave cases, after the beginning of the second week. Until 
this time, however, and throughout the entire course of more mild 
cases, the child is conscious of the desire, and can control the passage, 
or even wishes to be taken from the bed for the purpose. 

The urine is also, though more rarely, discharged involuntarily; in 



SPECIAL SYMPTOMS. 829 

rare cases, which may ultimately recover, retention of urine is present, 
and is of grave import. Eilliet never observed this sj^mptom, but we 
have seen it more than once, and especially in a boy aged five years, 
Avho required catheterization for several days successively, but who 
finally recovered. 

Eespiraiory and Circulatory Symptoms. — Even during the first week, 
there is usually more or less dry cough, with sonorous and sibilant rales 
over the posterior part of the lungs. Indeed, in some cases, we have 
known the cough and signs of catarrhal inflammation to be so marked 
in the first days of the disease, as to cause the attack to be regarded 
as one of severe acute bronchitis. Later in the disease, and owing 
merely to the passive hypostatic congestion of the lungs, and the accu- 
mulation of mucus in the bronchial tubes, the cough is apt to grow more 
frequent and troublesome, the respiration is hurried and oppressed, and 
auscultation reveals moist and dr}^ rales throughout both lungs. When 
pneumonia or bronchitis supervene, these symptoms of respiratory ob- 
struction increase to a marked degree. Extreme rapidity of breathing, 
with alterations in its character and rhythm, are also met with, how- 
ever, in cases where the pulmonary obstruction seems moderate, but 
where the nervous system is profound!}^ disturbed. 

The pulse is accelerated from the very first, and during the height of 
the disease, rises to 120, 140, or even 180, according to the age of the 
child. In grave cases it may become extremely small, feeble, and com- 
pressible, but scarcely ever is intermitting or irregular. 

The eruption of typhoid fever in children 2)resents precisely the same 
appearances as in the adult; it usually appears first on the upper part 
of the abdomen, and often presents several successive crops. It is, how- 
ever, more frequently absent entirely, and presents even greater irreg- 
ularities, as to the date of its appearance, in them than in adults. The 
abundance of the eruption certainly bears no relation whatever to the 
severity of the attack; and in a varying proportion of cases (7 in 30, 
Hillier), the most careful daily examination fails to detect the charac- 
teristic spots at any period of the case. The eruption makes its ap- 
pearance in a large majority of cases between the sixth and twelfth 
days, but the first spot has been observed so late as the twenty-fifth 
day (Hillier), or the twenty-ninth (Eilliet). 

Sudamina are frequently present in large numbers at any time after 
the ninth day. 

Epristaxis is very rarely abundant, but is met with in a majority of 
cases at some period after the third day. 

Nervous Symptoms. — In none of the symptoms of this disease is such 
variety observed as in those furnished by the nervous system. 

In mild cases, consciousness is retained throughout the attack; the 
expression of the face is stupid and heavy; the child is dull and dis- 
posed to doze during the day, but becomes feverish and restless to- 
wards night, and sleeps uneasily and wakes frequently. 

In more severe cases, the nervous symptoms soon become prominent. 
The face assumes an almost characteristic expression : the eyes are 



830 TYPHOID FEVER. 

dull and vacant, or bright and excited daring temporary delirium ; the 
cheeks present a circumscribed flush; the Hps are dry and parched; 
and the features remain almost motionless. 

Headache is sometimes complained of, and without doubt exists in 
many cases when the child is too young to call attention to it. It is 
especially observed in the earl}'' part of the attack, when there may be 
some hebetude and deafness present, and, according to Dr. Jenuer, 
ceases upon the appearance of delirium. 

This latter symptom rarely appears in marked degree before the 
second week, but then may become violent, the child crjnng out loudly, 
or muttering incoherently, and struggling violently to leave its bed. 
The delirium is rarely continuous but is more marked during the night, 
being rcj^laced during the day b^^ more or less profound stupor, which, 
however, rarely amounts to actual coma. 

Subsultus and carphologia, as well as muscular rigidity, are compara- 
tively rarely observed in children, and only in very grave cases. Con- 
vulsions, even of a general and violent character, are met with in a very 
small proportion of cases; they may occur in the earl}^ stages of cases 
which subsequentl}'' recover, or as one of the final phenomena in fatal 
cases. They are, however, at whatever stage they present themselves, 
of very grave im2:)ort. In a case mentioned by West, the convulsions 
recurred on two successive daj^s at the middle of the third week of the 
fever, and were succeeded by hemiplegia, \vhich continued, though 
gradually diminishing, for four days. The child was unconscious even 
before their occurrence, and continued so for several days, though he 
eventually recovered. 

As a general rule, the course of typhoid fever is much less apt to be 
attended by any complication in children than in adults; there are, how- 
ever, some which occur with considerable frequency. 

We have already stated that cough and signs of slight bronchitis are 
frequent in the early stage. In a considerable number of cases these 
symptoms become aggravated as the case progresses, and there may 
be a development of general bronchitis or even ^Dneumonia; more fre- 
quently, however, the condition of the lungs is rather one of hypostatic 
congestion than of true inflammation. These complications, when 
present in a marked degree, protract the case and add greatly to its 
danger. Pleurisy is comparatively rare. 

Perforation of the ileum, from ulceration of Peyer's patches, is more 
rare in children than in adults; but when present gives rise to the same 
symptoms, and leads to an equallj- rapidly fatal result. In some cases, 
its occurrence is announced by an attack of convulsions (Rilliet). 

Intestinal hemorrhage, on the other hand, is comparatively frequent; 
thus Hillier observed it four times out of thirty in which the stools 
were carefully examined. It is usually of grave significance, but is at 
times seen in mild cases, which recover readily. 

Earache is not infrequently observed after the height of the disease; 
in some cases it is followed by abundant purulent discharge. 

Inflammation of the parotid gland is much less frequent than in 



CONVALESCENCE. 831 

adults, as is also phlegmasia alba doleos, of which, however, there are 
instances on record. 

There is very little tendency to the formation of bed-sores in chil- 
dren, and with care in the management of the patient, they will scarcely 
ever occur. In some epidemics, gangrene of other parts, as of the vulva 
or cheek, have been observed in a few instances. Angina, and occasion- 
ally pseudo-membranous laryngitis, have also been noticed. 

We have seen that the urine is at times albuminous, and in these 
cases there is undoubtedly an intense congestion of the kidneys, which 
in very rare instances eventuates in Bright's disease. (Edema is not 
usually present, even when there is albuminuria, though Eilliet records 
two cases where anasarca, accompanied by albuminous urine, appeared 
on the fifth da}^, and lasted about a week. When oedema appears late 
in the course of the disease, it is probably to be rather attributed to a 
watery state of the blood and the debility of tho circulation. 

We have already seen that the febrile movement in typhoid fever, in 
children, presents such marked remissions, as to have led many obser- 
vers to apply the name infantile remittent fever to the disease. We 
must bear in mind, however, that it is far from being rare for a true 
malarial element to be present, complicating the case, and constituting 
it a typho- malarial fever. 

During the height of the disease, it is rare for any of the other erup- 
tive fevers to make their appearance ; but during convalescence, variola, 
rubeola, and scarlatina, have all been occasionally observed to appear, 
and run through their regular course. 

Tuberculosis is by some regarded as one of the most frequent 'of 
the sequelae of typhoid fever in childhood; and in some cases, indeed, 
it appears as though the extreme debility of constitution induced 
by the disease favored the development of tubercle in children with 
hereditary predisposition. It is probable, however, that in some cases 
also the early stage of acute tuberculosis has been mistaken for typhoid 
fever, with which, as will be more clearly pointed out, it possesses some 
strong features of resemblance. 

Convalescence. — The convalescence is, as in adults, tedious and un- 
certain. The child often remains for many weeks in a condition of great 
debility, and with such extreme nervous exhaustion, that hydrencepha- 
loid symptoms may even be present. 

The digestive system also manifests this debility in a most marked 
degree, and it requires the greatest tact and care to encourage the child 
to eat and, at the same time, to regulate the diet, since the slightest in- 
discretion will serve to excite serious symptoms. Not rarely death en- 
sues many weeks after the termination of the disease itself, in a state 
of intense emaciation, the child being worn out by persistent diarrhoea, 
which resists all change of diet and treatment. 

We have already alluded to the fact, that occasionally relapses have 
been observed, either without cause or following some trifling indiscre- 
tion, in which the symptoms of the fully developed disease have re- 
appeared and gone through their regular course. 



832 TYPHOID FEVER. 

Duration. — The duration of the fever varies according to the severity 
of the case. Even in the mildest forms it rarely begins to subside before 
the end of the second week, while much more frequently it is protracted 
until from the twentieth to the twenty-third day. In many eases, in- 
deed, convalescence cannot be said to be fairlj' entered upon before the 
end of the fourth week. 

Prognosis and Mortality. — The symptoms and conditions which in- 
dicate a favorable or unfavorable termination to the case are the same 
as present themselves in the adult, and may be readily gathered from 
the foregoing description. The mortality of typhoid fever is, however, 
decidedly less in children than in adults, partly owing to the compara- 
tive rarity of dangerous complications, and partly to the fact that the 
disease is usually of a less severe type. In mild cases, death scarcely 
ever occurs; and even in the more severe forms, the mortality is only 
from 5 to 10 per cent.^ under favorable hygienic circumstances. 

Diagnosis. — We have already stated that, partly owing to the imper- 
fect recognition of typhoid fever, and partly to the various names which 
were looselj' applied to this disease as occurring in children, it was for- 
merly frequentl}^ confounded with other affections. 

There are, however, several diseases from which it is not always easy, 
even with our improved knowledge of its peculiar symptoms, to distin- 
guish it. 

Thus, in some cases of gastro-enteritis, such as are not rare among 
children, and especially when the disease assumes a typhoid form, the 
resemblance to typhoid fever is so great as to have led Killiet and Bar- 
thez to assert that it is impossible to make a differential diagnosis. 

It should be borne in mind, however, that typhoid fever may often 
be traced to epidemic or endemic influence, and occasionally to conta- 
gion ; that it is very rarely possible to assign any direct exciting cause 
lor the attack ; and that it especially attacks children over five years 
of age, comparatively rarely those between two and five years, and 
very rarely those under the former age. Its onset is usually more 
gradual; the vomiting and diarrhcea are rarely so marked; the fever 
is more intense, the loss of strength greater and more rapid; while the 
marked dulness alternating with delirium during the night, the occur- 
rence of the characteristic eruption and of ejoistaxis, and the more fixed 
duration, form a group of symptoms which should serve, when present, 
to clearly distinguish these two diseases. 

In some cases, as already stated, the pulmonary complication, either 
in the ibrm of diffuse bronchitis or of pneumonia, appears so early and 
causes such marked S3'mptoms as tend to conceal those of the con- 
stitutional disease, and render care necessary to avoid overlooking it 
entirely. 

On the other hand, it occasionally happens, and more frequently in 
children than in adults, that cases of pneumonia assume a typhoid con- 
dition, and present very many of the general symptoms of typhoid fever. 
It will, however, usually be sufficient in cases of this kind to pay careful 
attention to the earlj^ symptoms and mode of development of the dis- 



DIAGNOSIS — TREATMENT. 

ease, as well as to the existence or absence of the characteristic symp- 
toms of typhoid fever, such as diarrhoea, tympany, ej^istaxis, rose-col- 
ored eruption, to avoid any error in diagnosis. 

In some cases of acute, general tuberculosis, in which the deposit 
affects the hrain, lungs, and intestinal canal, the symptoms may closely 
resemble those of typhoid fever. This form of tubercular disease may 
develop itself in the midst of seeming good health, the child losing 
strength and spirits; fever of a remittent type soon appearing; with 
vomiting, diarrhoea, tympanitic abdomen, and dry, furred tongue; and 
dulness of mind during the day, alternating with delirium at night. At 
the same time there is cough and rapidity of respiration, though the 
deposit in the lungs may be too slight and uinformly diffused to reveal 
itself by any positive phj^sical signs. 

In some such cases, indeed, it is only possible to form a probable 
diagnosis, based upon the age and previous history of the child; for 
acute general tuberculosis appears even at the earliest ages, and especi- 
ally in children who have an hereditary tendency to tubercular disease, 
or who are delicate and frail, or have lately passed through an attack 
of some one of the eruptive fevers, pr of hooping-cough; and upon the 
absence of eruption and the greater duration of the case. 

Usually, however, there is a sufficient ground for diagnosis furnished 
by the special symptoms, even early in the course of the case. Thus, 
in tj^phoid fever the vomiting in the early stage is rarely frequent or 
obstinate, and only follows eating; and, though the bowels may be 
constipated for a day or two, diarrhoea soon makes its appearance, and 
the abdomen begins early to enlarge. In acute tuberculosis, on the 
other hand, the vomiting in the early stage is usually both frequent 
and obstinate, and occurs entirely causeless!}'-; whilst the bowels are in 
most cases constipated, and the abdomen retracted until a much later 
period in the case, when the disease of the mucous membrane excites 
diarrhoea. The approach of fever in the tubercular disease is more 
slow, its course less regular, and its degree less intense, as a general 
rule, than in tyj)hoid fever. 

The nervous symptoms in the early stage of the two affections may 
be almost identical, but before long, in cases of tuberculosis, some of 
the unmistakable signs of tubercular meningitis, such as strabismus or 
partial paralysis, usually appear. Epistaxis is rare in tuberculosis, and, 
of course, the characteristic eruption of typhoid fever is absent, though 
it must be borne in mind that this is not constant in the latter disease. 
And, finally, though the pulmonary disease may in some cases be slight 
and not reveal itself by positive physical signs, most important aid is 
often derived from a careful exploration of the chest. 

Treatment. — Typhoid fever in childhood requires the same general 
plan of treatment as in adults. In mild cases little else is required 
than strict attention to all hygienic precautions, and a supporting, but 
fluid and digestible, diet. Whatever complications ensue, should of 
course be treated appropriately. There are, however, a few indications 
in regard to which it may be well to speak more in detail. 

53 



834 TYPHOID FEVER. 

When the fever is high, febrifuges, such as liq. amnionise acetatis and 
sp. ffitheris nitrosi should be given ; to which a little syr. ipecac, may 
be added, if the cough be troublesome. The surface of the body should 
be sponged daily with tepid water, to which a little vinegar may be 
added ; or the child may be carefully lifted for a few minutes every day 
or every other day into a bath of about 65° to 75°. 

If there is much gastric irritability in the early stage, food should be 
given in very Small quantities, and should be of the lightest character, 
as milk with lime-water or weak beef extract; counter-irritation may 
be employed in the form of mustard-plasters to the epigastrium ; or, if 
there be reason to think that the stomach contains undigested, irrita- 
ting food, an emetic of ipecacuanha may be given. If the bowels are 
constipated, very small doses of some mild laxative, as castor-oil or syr. 
rhei aromat. should be given during the first week; but when sponta- 
neous diarrhoea is present, it should, unless it becomes excessive, not be 
interfered with. When, however, the stools exceed three or four daily, 
chalk mixture, with some vegetable astringent and opium, or small 
doses of opium and acetate of lead, or of paregoric alone, may be ad- 
ministered. 

In ordinary cases, the nervous symptoms scarcely require any especial 
attention. When, however, they become marked, it will often suffice 
to apply wet cloths to the head and to administer warm mustard foot- 
baths to allay the agitation. In cases where delirium becomes extreme, 
with great nervous agitation, the above remedies should still be used, 
but, in addition, small doses of chloroform with camphor-water, or even 
of opium, should be given, and will often produce the happiest effect. 
Dr. West speaks highly in such cases of the combination of opium and 
tartar emetic, recommended by Graves in the treatment of the head- 
symptoms of typhus fever. It will be found, also, that chloral, in doses 
of five grains at three to five years, or of bromide of potassium, in doses 
of seven to ten grains at the same age, repeated according to the urgency 
of the symptoms and the effect produced, will often prove successful in 
affording relief. 

In regard to the occurrence of complications, we have already alluded 
to the remedies by which diarrhoea is to be checked if it becomes ex- 
cessive. When the symptoms of pulmonary obstruction become marked, 
frequent counter-irritation by mustard or turpentine should be applied 
to the chest, and stimulating expectorants, as carbonate or muriate of 
ammonia, administered internally. 

Hemorrhage from the bowels and peritonitis from perforation, must 
be treated exactly as in the adult, the one by astringents, either vege- 
table or mineral, the other by the free use of opium. 

Of the special remedies which are recommended in this disease, we 
may allude to the treatment by means of mineral acids, especialh^ the 
muriatic and nitromuriatic, which is highljr praised by some authorities. 

Quinia is necessary in many cases as a tonic when adj-namic symp- 
toms begin to appear, and is of service in cases attended with high tem- 
perature, when given in full doses with a view of reducing the excessive 



TREATMENT. 835 

heat of the body. In some cases, also, where the remittent character 
of the fever is marked, and where there is a suspicion that the case is 
complicated with a malarial element, it should be administered in full 
antiperiodic doses in the earliest stages. 

Opium is rarely necessary in the early part of the disease, unless it 
be required to check diarrhoea; but when, in the latter part of the 
second or third week, the delirium becomes extreme, and the child 
sleeps bat little, the night being spent in violent restless agitation, with 
loud screaming, opium should be fearlessly given until quiet sleep is 
produced. 

The oil of turpentine is to be administered under the same conditions 
which call for its use in adults. 

Stimulants are by no means absolutely necessary in all cases of typhoid 
fever in children. Excepting in the very mildest, however, it is prudent 
to administer them in small quantities after the middle of the second 
week. When, however, the condition of the child calls for their more 
free use, as shown by the frequent feeble pulse, rapid labored breathing, 
dry, brownish tongue, dulness alternating with noisy delirium, and other 
marked nervous symptoms, they should be given to the extent of f^iij 
to f^vj of sherry wine, or even of brandy, to children of six years old. 
It will be found in these cases that even such large amounts of stimu- 
lants as the above are very well borne by children. 

The food should be given in small quantities, and frequently repeated. 
It should throughout the entire course of the disease be exclusively 
fluid, consisting of milk, chicken-water, or the various animal broths. 
It is rarely difficult to regulate the diet of children suffering with this 
disease, since their entire loss of appetite renders them indifferent to 
all food, and they will usually take whatever is offered to them. 

During convalescence, the utmost care must be exercised, both in 
regard to food and exercise. Solid food should be permitted very 
gradually, and with much caution ; beginning with the lightest and 
most digestible forms, and watching the manner in which each article 
is digested. 

In those cases where the child remains a long time in a condition of 
extreme debility, with impaired power of digestion, the bitter tonics 
and iron should be given, if the stomach will tolerate them. Sea, or 
cold water bathing, change of residence, and the utmost attention to 
all hygienic rules, are also to be recommended. When there is any 
reason to dread the development of tubercular disease, this treatment 
must be carried out with the greatest assiduity; and, if the child can 
digest it, cod-liver oil may be given with advantage. 



CLASS VI. 

CACHECTIC DISEASES. 
ARTICLE I. 

SCROFULA. 

It does not seem appropriate, in a work whose chief character is de- 
signed to be practical, to enter upon a full discussion of the important 
pathological questions connected with the subject of scrofula, particu- 
larly in regard to its relations to simple chronic inflammation on the 
one hand and to tuberculosis on the other. Indeed, in some respects 
these questions may be said to be still in such an unsettled state that 
no definite position in regard to them can be assumed with confidence. 
We propose therefore to confine our remarks at present chiefly to a 
description of the most marked manifestations of scrofula as generally 
recognized, and to a discussion of the appropriate treatment. 

Definition; Characters. — The term scrofula is of very long stand- 
ing. It appears to have been originally applied to a peculiar cachectic 
state of the sj'stem in which there is a special tendency to enlargement 
of the lymphatic glands. Subsequently it has been employed in so 
many and such varied senses as to make it difficult in many cases to 
decide in which way it is meant to be understood. We ourselves would 
be understood to emplo}^ it much in the old sense, to indicate a peculiar 
constitutional condition in which there is a ^^ vulnerable'^ or irritable state 
of the lymphatics, which renders them liable to become enlarged from 
trifling causes, and at the same time indisposed to healthy reparative 
action; and which is also apt to manifest itself by various obstinate 
chronic inflammations of the skin, mucous or synovial membranes, or 
bones. 

Scrofula is undoubtedly closely associated with tuberculosis. It very 
often happens that the children of tuberculous parents are scrofulous. 
And again we frequently observe that patients who have snfl'ered with 
some chronic scrofulous afl^ection become the subjects of tuberculosis, 
even of the most acute miliary form. So also there is a stage, that of 
yellow cheesy degeneration, in which it is not possible to distinguish 
between products of a scrofulous and of a tuberculous character. Still, 
however, we do not regard these two cachexisB as identical, and enough 
points of difference can be indicated to fully support this opinion. Tuber- 
culosis, it is true, often follows scrofulous affections, just as it follows any 



CAUSES — SYMPTOMS. 837 

Other condition attended with the formation of cheesy deposits, which 
may infect the system and give rise to acute miliary tuberculosis. On 
the other hand, it is not common for tuberculous subjects to develop 
any manifestations of scrofula; and, as West points out, we frequently 
see whole families which display one or the other diathesis in its most 
intense form, and yet perfectly uncomplicated. Scrofula, moreover, is, 
far more markedly than tuberculosis, a disease of early life. The most 
common and characteristic of its manifestations also are very different 
from those of the latter disease; it affects the bones, the skin and ad- 
jacent mucous membranes, the glands, the synovial membranes in pref- 
erence to the serous membranes, the lungs, the solid abdominal organs, 
and the alimentary and respiratory mucous membranes. These differ- 
ences in the leading pathological tendencies of these two great cachexiie, 
as well as the many points of difference in the physical peculiarities of 
children who are liable to tuberculosis or scrofula, are clearly and forci- 
bly pointed out by Jenner in a clinical lecture published in The Med- 
ical Times and Gazette, 1860, p. 259. 

Causes. — Scrofula is, we think, in manj^ cases undoubtedly due to 
inherited predisposition. As in the case of other cachexise, the actual 
disease is not transmitted from parent to offspring, but merely so strong 
a tendency to its development that in some cases no care or favorable 
hygienic influences will overcome it. Not only do we meet w^ith scrofula 
in the children of parents who themselves have been scrofulous, but 
also in cases where a feeble and vitiated constitution has been inherited 
from parents affected with tuberculosis or constitutional syphilis. In 
other cases, it is undoubtedly acquired after birth, appearing in children 
born to parents of sound constitution. The causes which tend to thus 
develop it act by impairing the nutrition, and include such influences 
as insufficient, improper food, protracted exposure to damp, cold, and 
especially to vitiated atmospheres, attacks of certain diseases, which 
like measles, typhoid fever, and chronic malaria, exercise a remarkably 
injurious action upon nutrition. 

Symptoms. — Although by no means all scrofulous children present 
the same physical peculiarities, there are yet certain features so com- 
monly met with in such subjects as to have led to their recognition as 
forming together the symptoms of a scrofulous diathesis. Thus, as a rule, 
such children are heavy and lethargic in mind, and of phlegmatic tem- 
perament, with dull expression, and thick, opaque skin. The features 
are apt to be coarse, especially the lips and nose; the Ij^mphatic glands 
are perceptible to the touch ; the abdomen is apt to be full and large ; 
and the bones are large, with coarse, thick ends. 

There is nothing peculiar or pathognomonic about the special mani- 
festations of scrofula. Almost all of them may also appear as simple 
idiopathic affections due to some definite exciting cause, in children of 
entirely sound constitution. That which characterizes these same af- 
fections w^hen they occur in w^hat we term the scrofulous form, are 
the trivial causes which excite them, the inveterate obstinac}^ with 
w^hich they persist, and their association with other analogous phe- 



838 SCROFULA. 

nomena in the same subject. There is also in some cases a certain 
order of succession of the manifestations of scrofula which has even led 
to the division of its course into three stages, corresponding somewhat 
to the classic phases of constitutional syphilis. Thus in the earliest 
stage, the lymphatic glands and skin are chiefly affected; subsequently 
affections of the mucous membranes and cellular tissue make their ap- 
l^earance; and in the final and most aggravated form the bones and 
viscera suffer. We cannot affirm, however, that this division and order 
of succession of the manifestations of scrofula is by any means constant 
or even marked in many cases. 

Most of these manifestations appear as chronic inflammation of the 
part affected. At times such inflammation seems to arise spontane- 
ously, while more frequently some more or less trivial exciting cause 
can be assigned. Thus the scrofulous enlargement of any group of 
glands is apt to be preceded by irritation of the area whose lymphatics 
pass to the affected glands, as, for instance, enlargement of the cervical 
lymphatics follows eruptions on the scalp or behind the ears, or attacks 
of sore throat. 

Among the most frequent affections which are generally classed as 
scrofulous may be mentioned, without any reference to their frequency 
of occurrence, enlargement of the superficial lymphatic glands, cutane- 
ous eruptions, especially of the vesicular and pustular varieties, small 
subcutaneous abscesses, chronic inflammation of the mucous mem- 
branes which are continuous with the external skin, as of the conjunc- 
tiva, the membrane of the external auditory meatus, that of the nose, 
and of the vulva and vagina, chronic effusions in the synovial mem- 
branes, chronic ostitis with caries. 

The reader is referred for more detailed accounts of these numerous 
local scrofulous affections, to the special works which treat of the 
diseases of the skin or organs of special sense, or to general treatises 
upon surgery. Our own purpose is of necessity limited to a discussion 
of the general symptoms and treatment of the scrofulous cachexia, rather 
than of its numberless local manifestations. In the most advanced 
and severe forms of scrofula, lesions of various internal viscera nnxy be 
developed. Among the most frequent and clearly marked in their na- 
ture, of these, are caseous bronchitis and pneumonia, and albuminoid 
degeneration of the abdominal viscera, the liver, spleen, and kidneys. 
Bronchitis and pneumonia at times appear in forms which entitle them 
to be regarded as scrofulous from the first. At other times, they ap- 
parently originate as acute inflammatory affections, but which, owing to 
the strong scrofulous diathesis of the patient, pass into a chronic form 
characterized by the low grade of the morbid products developed, by 
the obstinate and intractable course the affections run, and by the 
marked tendency to the occurrence of caseous degeneration and de- 
structive changes in the diseased parts. In this condition, a sudden 
development of miliary tuberculosis not rarely occurs, either in the 
adjacent portions of the diseased organ, or throughout the other parts 
of the sj^stem. The exact nature of the primary changes in such cases 



SYMPTOMS. 839 

is. at the present moment, one of the most unsettled and disputed points 
in pathology. The reader will find a tolerably full description of the 
lesions and symptoms under the head of pulmonary phthisis. (See 
page 843.) 

The exact relation of albuminoid degeneration of the viscera to 
scrofula is also somewhat uncertain. Although one of the most fre- 
quent of the unfavorable sequelae of scrofulous affections, it cannot itself 
be regarded as scrofulous in nature, since it makes its appearance in 
connection with other cachectic states of the system. The attempt of 
Dickinson to associate it with the changes in the blood and tissues 
caused by prolonged suppuration (which so often occurs in scrofulous 
disease of the bones, joints, or glands), has not been altogether successful. 
Although it is undoubtedly true that in many cases where albuminoid 
degeneration has been developed there has been previous prolonged 
suppuration, there are many exceptions where the visceral lesions have 
apparently been induced directly in connection with the scrofulous or 
other cachexia. The occurrence of this sequel must always be antici- 
pated with anxiety in protracted and severe cases of scrofula. Although 
usually involving, simultaneously or in rapid succession, the various ab- 
dominal organs, the liver, spleen, kidneys, and gastro-intestinal canal, 
it may present a marked localization, for an indefinite time, in any of 
these parts. 

When one of the above solid organs is affected with advanced albumi- 
noid degeneration, it is found enlarged, though still preserving its orig- 
inal shape; the peritoneal capsule is unchanged; and on section the 
tissue presents a homogeneous, waxy, or lardaceous appearance, which 
is associated, when the section is examined by transmitted light, with 
abnormal translucence. The intimate nature of the change consists 
in an infiltration of the organ with a peculiar structureless albuminoid 
neoplasm or exudation. This first aftects the walls of the arterioles, 
and later the glandular cells of the organ. 

When the kidneys are involved, there is usually oedema, which ap- 
pears early and increases rapidly; the urine is abundant, clear, with 
but slight reduction in its specific gravity, contains a large amount of 
albumen, and deposits numerous hyaline tube-casts. Albuminoid dis- 
ease of the liver and spleen usually coexist. The organs are markedly 
enlarged, as can readily be detected by palpation and percussion. 
There is usually abdominal dropsy, with distension of the subcutaneous 
veins of the abdominal walls; and frequently there is also albuminuria 
and diarrhoea from coexisting disease of the kidneys and intestine. We 
have much less frequently observed marked albuminoid disease of the 
gastro-intestinal canal than of the solid abdominal organs, as above de- 
scribed. When it occurs, the walls of the stomach or intestine are 
thickened and present a peculiar homogeneous, glistening, and infiltra- 
ted appearance. The same microscopic changes are found as already 
described. The lesion of the mucous membrane is usually attended 
with chronic diarrhoea, and, if the stomach is also seriously involved, 
frequent and obstinate vomiting. Hemorrhages from the bowels have 



840 SCROFULA. 

been observed, but much less frequently than in the same condition in 
the adult. The general symptoms which mark the later stages of fatal 
cases of scrofula, especially when these serious visceral lesions have 
been developed, are expressive of the most profound ansemia and mal- 
nutrition. 

Diagnosis. — The recognition of the existence of scrofula depends, 
not so much upon the presence of any special symptom or local affec- 
tion, as upon the general marks of the scrofulous diathesis, the exist- 
ence of hereditary tendency, or of some of the well-known exciting 
causes; the spontaneity and order of evolution of the phenomena; and 
finally their intractable resistance to the ordinary remedies, and the 
marked benefit which is often found to follow the use of special anti- 
scrofulous treatment. 

Prognosis. — The prognosis in cases of scrofula must of course depend 
upon the intensity of the diathesis, the gravity of the local manifesta- 
tions, and the hygienic surroundings of the child. When the general 
health is fair, and the only scrofulous affections present are superficial, 
although the case is likely to prove obstinate and tedious, complete re- 
covery can often be insured. It must never be forgotten, however, that 
such children are liable to the recurrence of scrofulous disease in some 
other form, and even to the development of the grave visceral lesions we 
have above alluded to. In the later and more advanced stages of the 
cachexia, when serious disease of the osseous and glandular tissues exists, 
the prognosis becomes in the highest degree unfavorable. 

Treatment. — A great variety of local treatment — both medicinal 
and operative — is required for the various local scrofulous affections. 
We shall not, of course, attempt even to refer to these, but shall merely 
allude to the general principles that we think of prime importance; 
that, in the first place, all such affections should be cured as promptly 
as possible, and also that, in their treatment, the essential value of 
proper hygiene and constitutional remedies should never be forgotten. 

The preventive treatment is of the greatest value; but it merely con- 
sists in the employment, with special and continued care, in the case 
of any child who probably possesses a scrofulous diathesis, of all those 
precautions as to diet, dress, exercise, and residence, which sound hy- 
giene would dictate. In children, born of scrofulous or tuberculous 
parents, a wet-nurse should be secured even if the mother is able to 
suckle them; and under no circumstances should the attempt be made 
to rear them on artificial food. Later, when the child has been weaned, 
the diet should be of the most nutritious and digestible character, espe- 
cially containing a large proportion of well-selected animal food. The 
utmost care should also be exerted as to the dress, in order that it may 
be adapted to the season and sufficiently warm to prevent the child 
from contracting any of the catarrhal attacks, to which there is so 
great a liability in the scrofulous diathesis. Outdoor exercise in fair 
weather and gymnastic exercises indoors when it is unfit for the child 
to be exposed to the weather, must be enjoined. As a general rule, it 
may be said that the child should be encouraged to spend as much time 



TREATMENT. 841 

out of doors as possible, when the weather is fine, dry, and sunny. If 
the circumstances of the parents admit of it, the residence of the child 
should be chosen in an elevated, dry, and comparatively open part of 
the city, and for several months in each year it should be taken to the 
sea-shore, or to some elevated inland locality. While at the sea-shore, 
sea-bathing should be regularly followed, and throughout the rest of the 
3'ear brine-baths, made with either bay-salt, or rock-salt, may be used 
daily. All forms of catarrhal inflammation, as angina, conjunctivitis, 
enteritis, and the like, should receive prompt and careful attention and 
be cured as soon as possible, since there is danger, if they are allowed 
to continue, not onh' of their becoming chronjc and extremely obstinate, 
but also of troublesome glandular enlargements being induced by the 
protracted irritation. After any of the local manifestations of scrofula 
which we have above enumerated have made their appearance, the 
above hygienic management must be sedulously persisted in. There 
are also various medical substances which exercise a beneficial effect by 
their alterative and tonic action upon the general nutrition. Among 
these the best are cod-liver oil, various preparations of iodine and of 
iron. Cod-liver oil may be used alone, or combined with the compound 
syrup of the phosphates of the alkalies and iron. 

The preparations of iodine most frequently used, and which we have 
been led to prefer, are the compound tincture or solution of iodine, in 
the dose of from two to four drops three times a day, and the iodide of 
potassium, either alone, given in solution, as follows: 

R. — Potassii lodidi, gr. xxiv. 

Decoct. Sarsaparillte Comp., ..... f^iv. 
Ft. sol. Dose, a dessertspoonful to a tablespoonful thrice daily, at three to five 
years of age. 

Or in combination with the iodide of iron, as follows: 

R. — Potassii lodidi, gr. xlviij. 

Syr. Ferri lodidi, f^ij. 

Syr. Zingiberis, ....... f^x. 

Aquae, f^iss. 

Pt. sol. Dose, teaspoonful thrice daily in water, at five years of age. 

It is probable that the above is the best mode in which iron can be 
administered, though it is often desirable to give it in association with 
quinia or some other vegetable bitter, in order to stimulate the appetite 
and digestion. 

Mercury, despite its powerful absorbent action, is not to be recom- 
mended for the treatment of scrofulous enlargement of the glands, in 
any form in which it is likely to produce its characteristic effect upon 
the blood. We are satisfied, however, that in some very obstinate cases 
which resist all other modes of treatment, minute doses of the bi-chlo- 
ride or bin-iodide may be employed without risk, and with much advan- 
tao:e. 



842 TUBERCULOSIS. 

Arsenic deservedly occupies a high place among the internal reme- 
dies in scrofula. It may be given in combination with iron or quinia; 
or in some cases will be found of service in the form of small doses of 
Donovan's solution, the liquor hj^drargyri et arsenici iodidi of our Phar- 
macopoeia. 

When circumstances permit, the use of certain mineral waters, par- 
ticularly if the child can have the advantage of a temporary change of 
residence to the locality" of the spring, is often attended with marked 
benefit. The waters which prove most useful are the sulphurated and 
iodo-bromated. 



AETICLE II. 



TUBERC ULO SI S. 



This subject has received from many authors upon diseases of chil- 
dren, far less attention than it merits, under the idea that it is merely 
a repetition, upon a small scale, of the same disease in the adult, and 
not possessed of any individual characteristics. In fact, however, tu- 
berculosis in childhood is an affection possessing characters and pre- 
senting symptoms entirel}^ special, and differing from its manifestation 
in adult life both in causes, locality, and clinical history. 

Causes. — The causes which exert most manifest influence in its pro- 
duction are hereditarj^ tendency, and all those debilitating agencies 
which act directly or indirectly upon nutrition. Of these latter causes, 
early w^eaning is the most prominent. Thus, we have met with a case 
where a healthy woman, the mother of several vigorous children, all of 
whom she had nursed, gave birth to one which she was unable to suckle, 
and this child, after pining for some months, died of an attack of tuber- 
cular meningitis. A bad quality of the nurse's milk, or improper artifi- 
cial food after weaning, also exert a powerful influence in the produc- 
tion of tuberculosis 3 and not unfrequently its development has been 
traced to repeated attacks of indigestion or diarrhoea. 

It has also a tendency to develop itself after certain acute affections, 
especially in children predisposed by hereditary influence. Of these 
diseases, rubeola, pertussis, typhoid fever, and, accordiiig to Greenhow, 
variola, are most frequently followed by tuberculosis. 

There is still some difference of opinion in regard to the role which 
pneumonia plays in the development of tuberculosis. When the two 
coexist, the inflammation is by some regarded as a secondary affection, 
induced by the deposit of tubercle in the lung; while by others it is 
held that, amongst predisposed children, it is the pneumonia which 
causes the development of tuberculosis of the lung. We believe that 
pneumonia occupies each of these relations in a certain number of cases; 
but reliable statistics upon this point are still too scanty to determine 
the exact proportion. 



I 



ANATOMICAL APPEARANCES. 843 

Anatomical Appearances. — The most frequent seats of tubercular 
deposit in the child are the brain, constituting tubercular meningitis, 
Tvhich has already been treated of at length ; the branchial glands, the 
lungs, and the mesenteric glands and peritoneum. It is, however, one 
of the distinguishing features of tuberculosis in the 3^oung subject, that 
it is apt to involve several viscera simultaneously, while not unfre- 
quently the lungs remain free. Thus, in 312 children in whom Eilliet 
and Barthez found a deposit of tubercle in one or more of the viscera, 
the lungs were healthy in 47; while in 123 similar instances in the 
adult, Louis only found one such exception. 

Locality. — In bronchial phthisis, which generally accompanies pul- 
monary phthisis, but also exista as a separate affection (though, ac- 
cording to Bouchut, this is a rare occurrence), the glands are much en- 
larged and inclose tubercular matter, frequently in large proportion. 
This is esj)ecially marked in those glands which lie along the trachea 
and around its bifurcation, and, when many of them are involved and 
adherent to each other, they form masses varying in size from a hen's 
egg to a large apple. The deposit, which in by far the majority of 
cases exists as infiltrated tubercle, does not usually soften, though 
cases are recorded where such softening has occurred, and the fluid has 
been discharged through an opening into a bronchus. Obsolescence 
and calcification, however, are quite common terminations of bronchial 
tubercles; and when the lungs do not become involved in the morbid 
process, a cure may be effected by these transformations. Calcified 
tubercle may be eliminated through a communication between the 
gland and one of the air-passages; and a few cases are also reported 
where the oesophagus, trachea, and even the pulmonary artery have 
been perforated in this manner. Most of these tuberculous glands are 
inclosed in a distinct and dense capsule, which may attain the thickness 
of one or two lines, and is usually quite vascular. This fibrous capsule 
is due to the hypertrophy of the originally delicate cellular investment 
of the gland. 

Fulrii07iary Phthisis. — The anatomical characters of tuberculosis of the 
lungs in children, present several peculiarities, as distinguished from 
the same disease in adults. Thus gray granulations and crude miliary 
tubercles frequently exist in the lungs, independently of each other 
and of any other form of tubercular deposit. In the adult, Louis dis- 
covered miliary tubercles unassociated w^ith gray granulations only in 
2 out of 123 cases, or in 1.6 per cent.; and gray granulations alone in 
but 5 more, or 4 per cent. ; while in the child^ Eilliet and Barthez found 
miliary tubercles without gray granulations in 107 out of 265 cases, or 
in 40.4 per cent.; and gray granulations alone in o6 instances, or in 
13 per cent.; and the observations of West, " which are based on 102 
cases, yield 20 instances of the presence of miliary tubercles alone, and 
17 of the presence of gray granulations alone in the tissue of the lungs." 

The great frequency with which the so-called yellow infiltrated tuber- 
cle is observed in early life constitutes another anatomical peculiarity, 
Eilliet and Barthez, and West, having found it in from 23 to 33 per 



844 TUBERCULOSIS. 

cent, of their cases. This condition rarely exists as an isolated state, 
but is found in conjunction with gray granulations and crude yellow 
tubercles, and not iinfrequently also with advanced tuberculization of 
the bronchial glands. 

The rare occurrence of cavities in the lungs is a most striking pecu- 
liarity of phthisis in children. It is probably no exaggeration to say 
that, in adults, cavities are found in the lungs in 90 out of every 100 
cases of tuberculosis; whilst out of 265 cases of tuberculosis of the 
lungs in children that came under the notice of Eilliet and Barthez, 
only 77, or 29 per cent., presented cavities; they existed in only 23.5 
per cent, of West's cases, and Bouchut found them in but 3 out of 36 
cases. 

Occasioually the cavities resemble the vomicae found in the lungs of 
adults, and this "occurs with more frequency as we advance beyond the 
age of six years. In other cases, the excavation is produced by the soft- 
ening of very small tuberculous deposits, distinct, though in close prox- 
imity, which forms small vacuoles, communicating with each other and 
with the neighboring bronchial tubes. All three of M. Bouchut's cases 
appear to have been of this form. 

In addition to these two varieties of tuberculous cavities, there is 
still a third, produced by the simultaneous softening of considerable 
portions of a lung affected with yellow infiltration. This action, which 
is most commonly met with in very early life, and in cases w^hich pro- 
gress with great rapidity, pervades the whole of the tissue affected, 
instead of producing a central cavity. Cavities of this kind sometimes 
form very quickly, and involve large portions of lung, the w^hole of one 
lobe even being converted into a mere sac, with thin walls. 

There is another form of excavation occasionally noticed, which is 
not a true pulmonary vomica, but the result of the softening and evacu- 
ation of a tuberculous pulmonary gland. The diagnosis, however, may 
be rendered easy by reflecting that a pulmonary cavity of such small 
dimensions is hardlj^ ever solitary, unless it proceeds from the softening 
of tubercular infiltration, whilst the deposit of tubercle which takes 
place in the neighborhood of a diseased pulmonary gland is always in 
the form of distinct deposits, not of tubercular infiltration (West). 

The last anatomical peculiarity, already alluded to, of pulmonary 
phthisis in children, is its frequent complication with tubercular deposit 
in the bronchial glands. 

Peritoneum. — Tubercular deposit on the peritoneum rarely or never 
occurs without the presence of a similar disease in some other parts of 
the economy. It may be either general or partial in its disposition, 
though it is far more frequentlj^ the latter. The deposit varies also in 
its character, appearing generally in the form of yellow granulations 
or of miliary tubercles, either isolated or united into small masses. 
Gray granulations, however, are also of quite frequent occurrence. 

The relation which the tubercles bear to the peritoneum is not uni- 
form, though they are more frequentl}^ found deposited on its surface 
than beneath it. In 86 cases examined by Eilliet and Barthez, the seat 



ANATOMICAL APPEARANCES. 845 

Tvas as follows: intra-peritoiieal in 40; extra-peritoneal in 22; both 
intra- and extra-peritoneal in 14 ; in the other 10 cases the exact seat 
was doubtful. 

When the deposit involves the entire extent of the serous membrane, 
we find the anterior parietes of the abdomen adherent to the subjacent 
structures, and the viscera so matted together and adherent, as to foi'ni 
an almost inseparable mass. More frequently, however, the tuberculi- 
zation is partial, and even limited to the vicinity of a single organ. 
The peritoneum investing the diaphragm, especially that portion which 
is in contact with the liver or spleen, or the adjacent parietal perito- 
neum, is very often affected; and as tubercles rarely fail to be deposited 
in the peritoneum covering these viscera, we find them firmly adhering 
to the diaphragm or abdominal w^all. 

In some cases the omentum is the chief seat of the disease, and may 
either present numerous gray granulations scattered through its folds, 
or may be thickened or matted together from a kind of grayish tuber- 
cular infiltration, due to the coalescence of innumerable minute gray 
granulations. It is more rare to find the tuberculization limited to the 
intestines, merely causing adhesion of the adjoining coils. 

In examining the adhesions which are almost universally found to 
exist between the various organs and portions of peritoneum affected, 
we find them to present two elements. In the first place, the tubercu- 
lar deposits on the adjoining surfaces gradually coalesce as they increase 
in size, and finally unite the surfaces by more or less extensive patches 
of tubercular matter. And again, at the same time, the subacute in- 
flammation caused by their presence leads to the formation of cellular 
and fibrous adhesions as in cases of simple peritonitis. This is well 
seen in cases where some coils of the intestine present tubercular ad- 
hesions to each other, forming masses which can only be separated by 
rupturing the walls of the bowel, while between other coils the adhe- 
sions merely consist of delicate and easily lacerated cellular bands. 

It is a well-established fact that the tubercular granulations on the 
surface of the peritoneum have no tendency to perforate this mem- 
brane; but that the perforations which are occasionally found, especi- 
ally in the walls of the intestines, are due to the development and soft- 
ening of the subperitoneal tubercles, which always tend to penetrate 
into its cavity. This same law holds elsewhere, and it is on this account 
that the adhesions which so constantly form between tuberculous mem- 
branes are of such great value in preventing the escape of foreign 
matters into the serous cavities. In the intestines this action can be 
traced even further, and when tubercles exist under both layers of the 
peritoneum at a point of adhesion between two folds of intestine, as 
softening advances, the layers of peritoneum are destroyed, and the 
little collection of tuberculous pus remains confined only by the inner 
coats of the two layers of bowel. Sooner or later these also break 
down, the softened tubercle is discharged into the bowel, and a direct 
communication established betw^een distant parts of the intestinal 
canal, as between a fold of the ileum and the ascending or descending 



846 TUBERCULOSIS. 

colon. This perforation, then, is not caused by tuberculous ulceration 
of the mucous membrane ; nor does this latter affection bear any fixed 
relation to the degree of tuberculization of the peritoneum. 

There is generally some deposit of tubercle in the mesenteric glands 
in these cases; and when the splenic portion of the peritoneum is in- 
volved, we frequentl}' find an abundant deposit in this organ. 

Tuberculization of the mesenteric glands, or tabes mesenterica, offers 
few anatomical features in addition to those present in bronchial phthi- 
sis. It is, moreover, far from being a frequent form of the disease, for 
although, according to Rilliet and Barthez, some tubercle is found in 
these glands in one-half of all tuberculous subjects, it exists in consid- 
erable quantity only in one out of every sixteen of the whole number. 
The deposit generally appears as infiltrated tubercle, though not unfre- 
quently miliary tubercles are present. The glands attain a size vary- 
ing from that of an almond to a pigeon's Qgg, and occasionally, from 
the aggregation of several enlarged glands, a mass is formed double the 
size of the child's fist. 

The capsule which surrounds them is usually more delicate and less 
vascular than the same structure in tuberculous bronchial glands. The 
tubercular deposit here, as elsewhere, is liable to undergo calcification 
or softening, the latter process being more frequently met with. 

Owing both to the yielding nature of the abdominal walls, which do 
not resist the forward growth of the mesenteric glands, and to the mo- 
bility of the adjacent viscera, we never see the same degree of com- 
pression exerted on surrounding structures, as is noticed in tuberculi- 
zation of the bronchial glands. 

Occasionally, however, adhesions may form between a tuberculous 
mesenteric gland and a fold of the intestine, and ultimately result in 
perforation of the bowel. 

In thus describing these various lesions as being all tuberculous in 
their essential nature, we have purposely employed this term in the 
somewhat inaccurate and vague sense which was assigned to it until 
within the past few years. 

Eecognizing, as we distinctly do, but one elementarj^ form of tuber- 
culous deposit, the gray granulation or miliary tubercle, which may, it 
is true, undergo cheesy degeneration, it is evident that many of the 
cases in which extensive and uniform cheesy deposits are found, rather 
depend upon scrofulous inflammation of the part than upon true tuber- 
culous formation. It is comparatively rare to meet with such chees}^ 
deposits in the lungs in children, while, as already described, they occur 
very frequently both in the bronchial and mesenteric glands. And, 
therefore, we are disposed to believe that in many cases of so-called 
bronchial or mesenteric phthisis, the enlargement and degeneration of 
the glands is really due to an inflammatory process of a low and un- 
healthy type, excited by the previous occurrence of attacks of bron- 
chitis or enteritis, and leading to the formation of a caco-plastic Ij^mph 
which soon undergoes cheesy degeneration. 

It is in this way, doubtless, that the comparatively numerous cases 



SYMPTOMS. 847 

are to be ex^^lained in which such deposits soften and are evacuated, or 
undergo partial absorption and calcification, and where ultimately the 
child's health is restored. We have preferred, however, in the present 
edition, for practical purposes, to group the descriptions of these various 
conditions under one common head, being unwilling to separate them 
until more extended stud}^ shall have more clearly demonstrated the 
degree of resemblance which exists between true tuberculous matter 
and such caco-plastic inflammatory formations. 

Symptoms. — The symptoms of tuberculosis in children may be studied 
under the forms of bronchial phthisis; acute and chronic pulmonary 
phthisis; and tuberculization of the peritoneum and mesenteric glands. 

Bronchial Phthisis. — In addition to the general symptoms of tubercu- 
losis, which will be fully given under the head of pulmonary phthisis, 
the most marked symptoms of bronchial phthisis are those due to the 
mechanical effect of the enlarged and hardened glands upon the sur- 
rounding tissues. Our knowledge of the functions of the lymphatic 
glands is as yet so inaccurate that we are entirely unable to appreciate 
the symptoms of disordered action which are probably present in cases 
of extensive disease of these organs. 

Bronchial phthisis occurs in its best marked form between the ages 
of two and six years; and in many cases appears to be developed after 
some severe attack of bronchitis, either accompanying measles or aris- 
ing without apparent cause. 

The cough which, in the early stage, is hacking and not very trouble- 
some, soon acquires severity and becomes intermittent, recurring in 
paroxysms like those of pertussis. 

The respiration becomes habitually labored and oppressed, with a 
prolonged wheezing sound, as in asthmatic cases. 

The veins of the neck are often greatly distended, the distension be- 
coming extreme during the violent paroxysms of coughing; the face 
becomes puffy and cedematous, a condition occasionally extending to 
the upper extremities; and, as West points out, the superficial vessels 
of the thorax become enlarged, just as those of the abdomen do in cases 
of cirrhosis of the liver. The obstruction to the return of blood from 
the superior vena cava is further shown by the occurrence of ei:)istaxis, 
or even of hemorrhage into the arachnoid; and the compression of the 
pulmonary tissue occasionally produces haemoptysis and oedema of the 
lungs. Dr. Jenner has seen hydrothorax produced from compression 
of the vena azygos. 

The oesophagus does not always escape the encroachment of the 
glands, but may be so compressed as to produce dysphagia. 

It is hardly necessary to say that so long as the tubercular deposit 
remains small, it may exist without causing any s^^mptoms, and it is 
only w^hen several glands become infiltrated with tubercle, enlarged and 
firm, that they give rise either to the symptoms already enumerated, 
or to the physical signs below alluded to. 

Physical Signs. — In estimating the value of these, it is necessary to 
constantly bear in mind the fact that the enlarged and tuberculous bron- 



848 TUBERCULOSIS. 

chial glands, while the}" still surround the trachea and bronchi, also 
come into contact with the spinal column, or, in a few cases, with the 
sternum. From their solidity, and the consequent readiness with which 
they are thrown into vibration, they transmit directly to the ear and 
seem to exaggerate many respirator}^ sounds, which are in reality j^ro- 
duced at a distance from the thoracic walls, and which are either en- 
tirely normal or dependent upon a small amount of disease. 

It is also due to these relations, that the signs, both of auscultation 
and percussion, of bronchial phthisis are best detected at the summit 
of the lungs posteriorly, or at the level of the vertebrae with which the 
enlarged glands come in contact. 

Our knowledge of these important considerations is chiefly due to 
the investigations of Eilliet and Barthez. 

Percussion. — In the young child in health, there is a diminution in 
resonance over the manubrium of the sternum, owing to the remains 
of the thymus gland; but, in some cases of marked bronchial phthisis, 
this dulness extends both downwards and laterally to a varying but 
perceptible degree, owing to the projection of the enlarged glands into 
the anterior mediastinum. 

More generally, however, as we have said, the tuberculous glands are 
in contact with the spinal column, so that we find dulness on percus- 
sion in the interscapular space as a pretty constant and characteristic 
symptom. 

According to Dr. Jenner, it is common to have a cracked-pot sound 
on percussing the cartilages of the upper three ribs on one or both sides. 
This is due to the fact that the enlarged glands accompanying the bron- 
chial tubes frequently extend under the anterior margin of the lungs^ 
so that, in percussing, the air-containing lung is compressed between 
the solid mass of glands behind and the in-driven parietes in front, and 
the air is forced out suddenly from the healthy layer of lung, producing 
the chinking sound. 

Auscultation often reveals true tubular breathing over the upper part 
of the sternum, extending almost to the base of the heart. In those 
cases where a large bronchial tube is compressed or occluded, we, of 
course, find an enfeebled or extinct respiratory murmur over the corre- 
sponding lung segment. 

Occasionally the enlarged glands compress the superior vena cava, 
and give rise to a permanent venous hum; or a systolic murmur, having 
its seat of greatest intensity at the second left interspace, may be pro- 
duced by similar compression of the pulmonary artery. 

There is one characteristic, however, of this form of phthisis, which 
is especially dwelt upon by Dr. AYest, and which it is well to bear in 
mind, to avoid being misled. This is the frequent occurrence of great 
fluctuations in the condition of the patient; so that, even when the 
rapid breathing, frequent cough, emaciation and loss of strength would 
betoken a speedil}^ fatal issue, a pause will occur in the progress of the 
disease, during which the diminution of au}^ bronchitic complication, 
with partial disappearance of the dyspnoea and cough, and the return 



1 



SYMPTOMS. 849 

of flesh and 'strength to the little patient, all tend to awaken delusive 
hopes. In the great majority of cases, this respite is but brief, and the 
disease again resumes its onward course; but there are well-authenti- 
cated cases on record in which the gravest symptoms have gradually 
disappeared, and the child has ultimately regained fair health. In 
these cases, the tuberculous deposit may either have undergone creta- 
ceous degeneration, or, having softened and formed an opening into a 
bronchus, have been expectorated. 

The characteristics of bronchial phthisis, which we have been con- 
sidering, are thus summed up by West: 

" 1. The frequent development of its symptoms out of one or more 
attacks of bronchitis. 

" 2. The peculiar paroxj'smal cough which attends it, resembling that 
of incipient pertussis. 

" 3. The great and frequent fluctuations in the patient's condition, 
and the occasional and apparently causeless aggravation both of the 
cough and dyspnoea." 

Symptoms of Pulmonary Phthisis. — Yaluable as are the general symp- 
toms of tuberculosis in the adult, it is in the young child peculiarly that 
they reach their highest importance, owing either to the absence or 
the difiiculty of appreciation of many symptoms which aid greatly in 
the diagnosis of phthisis in adult life. 

It is necessary, therefore, to examine with the greatest care the 
child's hereditary tendencies, its pas^t history, and its appearance and 
physical development. Thus it is in cases of inherited tuberculosis 
that we see its characteristic features most strongly marked, in the tall, 
slim frame; the firm bones, with small and yielding cartilages; the 
delicate diaphanous complexion; the fine, silky hair; the active, often 
precocious intelligence; the ease with which the general health is 
afl'ected by slight causes, and the peculiar proneness to catch cold on 
the least exposure. By careful attention to these and other similar 
points, as much, or often more valuable information can be obtained in 
the phthisis of children, than from the most careful investigation of the 
physical signs. 

In enumerating the symptoms, it is unnecessary to detail those which 
exist in common with pulmonary phthisis in the adalt, save to point 
out any particular in which they may differ as seen in the young sub- 
ject. 

The cough varies much, in accordance with the varying amount of 
bronchial irritation, being at one time scarcely troublesome, or so ag- 
gravated and accompanied with such violent dyspnoea, from some in- 
tercurrent attack of bronchitis, as to threaten immediate death. 

It not unfrequently has a somewhat paroxysmal character, from the 
accompanying tuberculization of the bronchial glands. One of the 
most marked peculiarities of the cough in the phthisis of children is 
the entire absence of expectoration, since the secretions are either re- 
tained in the bronchial tubes, or, if raised into the pharynx, are swal- 
lowed without any eff'ort at expulsion. 

54 



850 TUBERCULOSIS. 

Jlcemoptysis very rarely occurs in the early stage or during the prog- 
ress of the disease; and when it occurs as the cause of sudden death, is 
due to the complication with bronchial phthisis, rather than to the rup- 
ture of a bloodvessel in a j^ulmonary vomica. 

The temperature of the body is, as a rule, higher than normal, although 
it presents fluctuations on different days, and even at different hours of 
the same day; at times being normal, and again rising as high as 102°, 
or more. The greatest elevation of the temperature is generally no- 
ticed at night, and is usually accompanied by flushing of one or both 
cheeks ; but it is rare to find the colliquative night-sweats which prove 
so exhausting to adults. 

The pulse is always accelerated, and becomes very frequent as the 
temperature rises. 

The appetite is capricious, the tongue furred, and the digestion im- 
perfect; the bowels alternate from a state of constipation to diarrhoea, 
and the stools are unhealthy in appearance, being generally putty-like 
or clay-colored. Naturally, with this disturbed state of the primal vise, 
nutrition is seriously impaired, and the child steadilj- loses flesh and 
strength. Indeed, in very many cases, the little patient presents 
merely the symptoms of impaired nutrition, becomes languid and 
drooping, and loses appetite, strength, and flesh, for many weeks be- 
fore the development of cough reveals the lungs as the seat of the 
disease. 

Physical Signs. — We have already remarked the fact that in the in- 
vestigation of phthisis, the physical signs are of much less value in the 
case of children than in adults. This arises not only from peculiarities 
of the physical and moral organization in childhood, but also from the 
mode in which the tuberculous deposit takes place. Thus, as a rule, 
the deposit of tubercle in the lungs of children is more genei-ally dif- 
fused and uniform; so that we lose to a great degree the advantages 
derived in adults from a comparison of the results of auscultation and 
percussion in one part, with those obtained in another. For the same 
reason, we are also deprived of those signs which, in the adult, are 
developed in a single point: as, for instance, the coarse breathing, which 
is of so much diagnostic importance as one of the earliest signs of the 
deposit of tubercle at the apex of the lungs. 

Another source of difiiculty and error lies in the fact already alluded 
to, that the bronchial glands, when enlarged by the deposit of tubercle, 
as so constantly happens in conjunction with the pulmonary phthisis of 
children, are brought into contact with the thoracic walls, and transmit 
many sounds with intensified force. It is thus that prolongation of the 
expiratory sound beneath the clavicle, and jerking respiration^ lose 
much of the importance they have as signs of the early stage of phthis- 
is in adults. For although, when heard in children, they should always 
be regarded as probable evidence of phthisis, they have frequently been 
noticed in cases whose progress shows the tubercular deposit to have 
been, at the most, trifling. In the same way, caution must be used not 
to mistake the blowing sound, mixed with moist rales, which is thus 



SYMPTOMS OF PULMONAKY PHTHISIS. 851 

transmitted from a compressed bronchial tube containing miicns, for a 
large tubercular vomica. The only way in which this mistake, and 
the consequent too unfavorable prognosis, can be avoided, is by com- 
paring daily the results of auscultation and percussion, and noticing 
whether they remain exactly the same, or whether, while the dulness 
on percussion over the enlarged glands persists, the results of ausculta- 
tion vary from day to day with the varying amount of compression of 
the bronchus and the nature of its contents. 

A still further source of difficulty results from the loss of all the in- 
formation which is derived, in older persons, from the vocal resonance 
and its alterations. And again, owing to the excitability of children, 
patient and prolonged observation is required, both as to the situation, 
degree, extent, and duration of any inequality of breathing, before any 
conclusion can be drawn from it. 

Finally, the extreme resonance of the thorax in early life tends to 
vitiate the results of percussion by preventing the recognition of fine 
variations of sonority, such as are readily detected in more advanced 
life. 

In addition, moreover, to these numerous sources of difficulty in the 
application of auscultation and percussion, we are compelled to add the 
fact that there is not a single physical sign peculiar to pulmonary 
phthisis in children; the dulness in the interscapular space in bronchial 
phthisis being indeed the only characteristic sign developed in either 
form, and even this does not appear until the glands have attained a 
very large size. 

"We have thus far been considering the symptoms of pulmonary 
phthisis in its usual moderatel}^ acute form, but it is necessary to be 
aware that in some cases it deviates from this course, being at one time 
extremely rapid, and at another very chronic in its progress. 

In the acute cases, we often find that there has been a previous de- 
posit of tubercle or of caseous inflammatory exudation in different parts 
of the economy, though to so small an extent as scarcely to have in- 
terfered with nutrition or the performance of the functions, or to have 
attracted the least attention. 

In such a state of system, death may be produced in a few days or 
weeks by an acute development of tubercle. When this occurs in the 
lungs, it is not unfrequently attended by inflammation of the pulmonary 
parenchyma, constituting tuberculous pneumonia; and, whatever may 
be the view entertained as to the relation between the inflammation 
and the tubercular deposit, the recognition of this latter element is of 
the greatest importance, from its bearing on the treatment to be 
adopted. 

In tuberculous pneurnonia, in addition to the hereditary tendency and 
past history of the child, we rarely find the same heat of skin or vascu- 
lar excitement as in pure pneumonia. The degree of oppression of the 
chest is also, from the beginning, out of proportion to the catarrhal or 
bronchial symptoms with which the case sets in. And auscultation 
reveals both that the amount of inflamed luno^-tissue is not sufficient to 



852 TUBERCULOSIS. 

account for the dyspnoea, and that the rales developed are of the sub- 
crepitant and mucous varieties, rather than the true fine crepitant rale 
of uncomplicated pneumonia. 

In the chronic form of phthisis alluded to, the symptoms may be pro- 
longed during several 3'ears. They consist of progressive emaciation, 
chronic cough, with or without expectoration according to the age of 
the patient, and the physical signs of more or less advanced tubercular 
deposit. In favorable cases, it is not unusual for some degree of tem- 
porary improvement to occur in the general symptoms, and in some 
rare cases the child slowly regains good health, and the physical signs 
gradually diminish, leaving merely some duluess and feeble respiration 
at 2)oint3 where positive signs of advanced tuberculous disease previ- 
ously existed. 

Symptoms of Tuberculous Peritonitis.— The peritoneum may either 
become implicated late in the course of general tuberculosis, or it may 
be the first structure involved. Apart, however, from the general symp- 
toms of the tuberculous cachexia which in some cases precede its ap- 
pearance, there are few symptoms of much diagnostic value during 
its earl}' stage. Thus the child retains its appetite and spirits; does 
not lose flesh rapidly; and only complains of occasional and apparently 
causeless abdominal pain. This condition does not, however, last long; 
the nutrition soon fails, the appetite becomes capricious, the bowels 
irregular, the colicky pains more frequent and severe, and the abdomen 
acquires an abnormal size and appearance. These symptoms, however, 
merit a more detailed allusion. The tongue rarely indicates, either by 
dryness or furring, any serious disturbance of the digestive functions. 
The bowels are almost invariably loose, or alternations of constipation 
and diarrhoea present themselves, the stools usually being unhealthy in 
appearance. This condition frequently appears to depend upon inflam- 
mation or tuberculous ulceration of the intestines. Vomiting is not 
usually present; it is rarely spontaneous, and merely consists in the 
occasional rejection of alimentary matters. 

Pain in the abdomen has been mentioned as one of the earliest 
symptoms. It is rarely constant or confined to the seat of the lesion, 
but is rather shifting, intermittent, and colicky in its nature, recurring 
with greater or less frequency. There is also tenderness on pressure 
over the abdomen, which becomes especially marked during the later 
stages of the disease, though in some cases the abdomen remains indo- 
lent throughout. At a variable period after the appearance of the pre- 
ceding symptoms, and sometimes simultaneously with the occurrence 
of colickj^ pains, the abdomen undergoes a marked modification in its 
size and shape. It becomes tense and large, and assumes an oval or 
globular form, the depressions and fossae being all effaced. It gener- 
ally retains its tympanitic note u^^on percussion; and in proportion as 
the distension increases, the sound becomes more and more tympanitic. 
The tension often varies without any apparent cause; and when it is 
much diminished, an imperfect sense of fluctuation maybe obtained by 
filliping the sides of the abdomen. This sign is rarely due to any as- 



SYMPTOMS. 853 

cites being present, but is bej'ond doubt rightly explained by Rilliet 
and Barthez, as due to the transmission of the impulse of the hand by 
the agglutinated intestinal mass. 

It is only in very exceptional cases that even the most careful per- 
cussion or palpation will detect any inequalities in the abdominal walls, 
due to the presence of large tuberculous patches. In every case in 
which the last-named observers detected any abdominal tumor, the 
omentum was found to be the chief seat of the tuberculous deposit. 

After this condition of the abdomen has persisted some time, the dis- 
tended skin desquamates, and assumes a rough and dirty appearance. 
At about the same period, usually, the cutaneous veins of the abdomen 
become prominent and dilated, owing to the obstruction to the abdom- 
inal circulation. 

As the case progresses, and the general symptoms assume more 
gravity, these local symptoms become more pronounced. Like all 
forms of tuberculosis in children, however, the advance of this disease 
is rarely uniform, and intermissions and fluctuations in the symptoms 
are often noticed. Toward the close of life, all the symptoms usually 
undergo aggravation, and the remissions become more and more rare 
and brief. 

Death is either produced by the advance of tuberculous disease in the 
lungs, or by tubercular meningitis; or the little patient sinks from 
sheer exhaustion under the persistent diarrhoea and the repeated acces- 
sions of peritoneal disease. 

Symptoms of Tuberculosis of the Mesenteric Glands. — The symptoms of 
this condition are even less positive and diagnostic than those of tu- 
berculous peritonitis. So long as the glands remain only moderately 
enlarged, buried as they are beneath the small intestine, it is impossible 
to detect their presence, especially as the absorption of chyle is not 
materially interfered with. 

We have already mentioned, moreover, the comparative rarity of 
symptoms due to the pressure of the enlarged glands upon neighbor- 
ing structures, such as perforation or compression of the intestines, and 
dilatation of the cutaneous veins, or oedema. 

The modifications of the size and shape of the abdomen occasionally 
furnish useful information. It is rarely so large and tense as in tuber- 
culous peritonitis, and its shape is rather globular than oval. 

There is scarcely any tenderness on pressure over the abdomen, 
unless there is some accompanying peritonitis. 

The only really pathognomonic symptom, indeed, is the detection of 
the enlarged glands by palpation. This, however, is far from being 
possible in all cases, even when the bulk of the glands is very consid- 
erable, as they are frequently covered and concealed by the intestines. 

It is, in fact, only in those cases where the abdomen is supple and 
relaxed, that we can establish the presence of the tumor, which is usu- 
ally lobulated, varying in size from a hen's Qgg to a large orange, and 
seated in the neighborhood of the umbilicus. 

The digestive system here also presents more or less marked disturb- 



854 TUBERCULOSIS. 

aaces; the bowels in particulai' being loose, a condition generally due 
to the existence of tuberculous ulceration of the intestine. 

The general symptoms which accompany tuberculization of the 
mesenteric glands alone, are often not so marked as when other organs 
are aifected ; in fact, MM. Eilliet and Barthez assert that they have not 
met with a case in which this affection, isolated from all others, has 
produced any considerable emaciation. 

Duration. — The duration of tuberculosis in children, as might have 
been expected, varies considerably according to the position and sur- 
roundings of the patients. In large hospitals, where the children have 
not the advantage of the best hygienic influences, the majority of cases 
terminate in from 3 to 7 months, though occasionally protracted to up- 
wards of 2 3'ears. In private practice, on the other hand, many cases 
of chronic phthisis are met with, in which the disease continues for 3, 
4, or even 5 years before producing death. It is extremely difficult to 
assign any probable duration for either tuberculous peritonitis or tabes 
mesenterica, as they can rarely be diagnosed during the early stages 
of their development. 

Diagnosis. — The danger in regard to the diagnosis of phthisis in 
children is not so much of entirely overlooking the nature of the dis- 
ease, as of overestimating its amount. We have already given the 
reasons why the physical signs of pulmonary and bronchial tubercu- 
losis in children are less reliable and more difficult to appreciate than 
in adults. A proper attention to the hereditary tendencies and indi- 
vidual history of the child ; a close scrutiny of its physical conformation 
and development, with an intelligent interpretation of the physical 
signs, will, however, generally suffice to prevent any serious error. 

In the earlier stages of the more acute forms of phthisis, the disease 
with which it is most apt to be confounded is remittent fever; from 
which it may be distinguished by the history of malarial exposure, by 
the definite commencement of the case, and by the very marked exacer- 
bations which occur towards night, attended with high fever, great 
heat of skin, and considerable delirium. In its more chronic forms, 
the diagnosis of pulmonary phthisis from chronic bronchitis is often at- 
tended with the greatest difficulty. In fact, the physical signs of the 
two conditions are frequently so entirel}^ analogous, that it is only by 
the general symptoms of tuberculosis, the greater amount of hectic 
irritation, the more rapid emaciation, and the frequent supervention 
of tubercular deposit in other organs, that a diagnosis can be estab- 
lished. 

We have already dwelt upon the value of abnormal development of 
the abdomen as a symptom of tubercular peritonitis. There are, how- 
ever, many cases of simple functional derangement of the intestines, in 
which no suspicion of tuberculous deposit can be entertained, where 
this symptom is also noticed. It is due to this circumstance that tuber- 
cular disease of the peritoneum and mesenteric glands w^as formerly 
considered of such frequent occurrence. A careful regard, however, to 
the age of the patient; for simple distension of the abdomen occurs 



PROGNOSIS — MODES OF DEATH. 855 

jreiierally in infancy, whilst tuberculous peritonitis is most frequent 
after the age of 3 years ; and to the effects of simple remedies, will 
usually remove anj- doubt. 

The cases which are most apt to be confounded with tabes raesen- 
terica are those in which abdominal tumors, due to some other cause, 
are present. Thus, in extensive tubei'cular deposit in the omentum, 
we may have, in addition to the general symptoms of tuberculosis, a 
well-defined tumor about the middle of the abdomen. The greater 
degree of tenderness of the abdomen, and the mobility in this case, 
may, however, serve to distinguish it. Again, it is not rare to find in 
cases of digestive derangement, where irregular action of the bowels 
with more or less pain may have been present, a distinct and only 
slightly movable tumor in the abdomen, due to the impaction of the 
intestine with hardened faeces. A careful consideration, however, of 
the position of these masses, which is generally in one or the other iliac 
fossa; their entire painlessness and doughy character upon palpation, 
and their complete disappearance after the administration of laxatives 
and enemata, will reveal their true nature. 

Prognosis. — The very name of tuberculosis has grown, with only too 
much reason, to be almost synonymous with impending, unavoidable 
death. And yet, while pulmonary phthisis shows the same fatal tend- 
ency in childhood as in adult life, the prognosis is somewhat less 
gloomy. For not only does well-directed treatment occasionally render 
a deposit of tubercle in the lungs, whose existence has been proved by 
the symptoms of the incipient stage, inert and obsolescent; but in rare 
cases, where the deposit has advanced to softening and destruction of 
lung-tissue, a cure has been slowly effected by the evacuation of the 
softened tubercle and the gradual cicatrization of the cavity. 

In tuberculization of the bronchial and mesenteric glands, moreover, 
numerous cases have been noticed where the glands have undergone 
complete calcification, and the progress of the disease has been arrested. 

While, therefore, the prognosis must ever be grave and unfavorable, 
we must bear in mind the possibility of recovery when the hereditary 
tendency of the child is not too strongly pronounced, and the actual 
tuberculous deposit not extensive or rapidly progressing. 

Modes of Death. — Having thus spoken briefly of the prognosis, a 
few words will suffice to call attention to the various modes in which 
phthisis brings about a fatal issue in children. 

In the majority of cases, death occurs from sheer exhaustion of the 
powers of life, from impaired nutrition and perverted functions. In a 
few instances of bronchial phthisis, death is suddenlj^ caused by copious 
hemorrhage, owing to the perforation of one of the pulmonary blood- 
vessels. 

The immediate cause of death is frequently found in an intercurrent 
attack of bronchitis, pneumonia, or peritonitis; while, in other cases, 
the cerebral symptoms which precede the fatal event, show that the 
membranes of the brain have become the seat of tuberculous deposit. 

It is not unusual, moreover, whether the original seat of the tubercu- 



856 TUBERCULOSIS. 

Ions deposit have been in the abdomen or thorax, for marked abdomi- 
nal symptoms to be developed towards the close of the case; the tuber- 
culous ulceration of the intestines serving to maintain an uncontrollable 
and exhausting diarrhoea. 

Treatment. — Prophylactic. — In children whose parents are tubercu- 
lous, and who in earlj^ life give evidence of delicate health, the prophy- 
laxis becomes most important. The infant should be kept at the 
mother's breast up to the age of fifteen or eighteen months; but in 
case the mother be herself tuberculous, on no account should she be 
allowed to nurse the child, for whom a healthy wet-nurse should be im- 
mediately procured. By attention to this precaution, we have suc- 
ceeded in raising children of tuberculous mothers, who had suckled 
their previous children and had lost them all in early life from tubercu- 
lous disease. 

As the child advances in age, every caution should be paid to its food 
and clothing, to securing sufficient exercise in the open air, and free 
ventilation in its sleeping apartment. When the circumstances of the 
parents permit it, it is of the greatest consequence that the child should 
enjoy the benefits of a country life, in some healthy, invigorating at- 
mosphere, for four or six months out of every year. 

The child should further be guarded sedulously from the ailments in- 
cident to early life, and especially from hooping-cough and measles; 
and the slightest disturbance of either the respiratory or digestive 
functions should receive prompt and careful treatment; nor should we 
be tempted to discontinue these efforts, even if positive signs of tuber- 
culous deposit appear; for the possibility of these deposits in childhood 
becoming latent or being evacuated, and the general health re-estab- 
lished, should never be lost sight of. 

Curative. — Little need be said of the treatment of fully developed tu- 
berculosis in children, since the same indications present themselves as 
in adults, and call for the same remedies. The most essential points in 
the treatment are attention to all hygienic conditions, careful regula- 
tion of the diet, and the administration of remedies calculated to im- 
prove nutrition and primary assimilation. 

It is indeed impossible to overestimate the importance of maintain- 
ing the appetite and powers of digestion ; and if these show ^ny sign 
of failing, we should resort to some of the bitter vegetable tonics, of 
which, perhaps, the combination of tincture of nux vomica, gtt. ij to v, 
with the compound tincture of gentian, ttj^ xv to xxx, according to the 
age of the child, is most desirable. On the other hand, if we find reason 
to believe that any remedy we are administering disturbs the nutrition 
of the child, disgusts it, lessens its appetite, or rouses violent opposition 
at every dose, it should be instantly abandoned as producing the very 
eifect w^e most desire to avoid. 

The child should be strongly encouraged to take nourishing food at 
regular intervals, and so soon as any of the articles of its diet become 
unattractive, other preparations of similar nature should be substituted. 
Milk should enter largely into the diet, and ought to be taken at least 



TREATMENT. 857 

eveiy morning and evening. Tender, finel}^ divided meat should be 
eaten at the midday meal, in such quantities as the digestion will easily 
bear. If marked signs of debility present themselves, a few drachms 
of good brandy may be taken at intervals through the day, with advan- 
tage. 

When the stomach does not reject it, there are few remedies whose 
action is more beneficial than cod-liver oil, given in the dose of a tea- 
spoonful or even less, three times a day. In many instances, children 
soon become accustomed to the taste of this substance and even grow 
to relish it almost as a luxury, and to take it eagerly; in some cases, 
however, the taste is so unpleasant that the children refuse to take it, 
and it is, therefore, advisable in such instances to prescribe it in the com- 
bination recommended at page 366, at least during the first few weeks 
of its administration. 

In those cases where it is impossible to administer cod-liver oil inter- 
nally, very good results may often be obtained here, as well as under 
similar circumstances in other wasting diseases of children, by the use 
of the oil by inunction. 

Iron and its various preparations are strongly indicated, and we can 
generally find some of the milder forms which will be readily tolerated. 
In those cases where there is considerable implication of the lymphatic 
glands, the syrup of the iodide of iron appears especially useful, and 
this may be well given alternately or in conjunction with iodide of po- 
tassium. 

Sea-bathing is strongly recommended, especially in the tuberculiza- 
tion of the glandular system ; or, when this is not attainable, baths in 
which some tonic drug has been mixed may be used. 

In tuberculous deposit in the peritoneum or mesenteric glands, the 
diet must be regulated with peculiar care; the most bland, unirritating, 
and digestible food being selected. If, however, despite our precautions, 
diarrhoea should make its appearance, the various astringents in combi- 
nation with opium should be given freely. The pain in the abdomen, 
which is frequently so severe in these forms of tuberculosis, may be re- 
lieved by the application of sinapisms, or of warm anodyne poultices, 
or by gentle friction with a sedative liniment. 

When the symptoms of any intercurrent inflammation in the diseased 
organ present themselves, we must limit our treatment to the applica- 
tion of a few cups or leeches over the part, and the administration of 
a less stimulating diet, with some mild febrifuge. When the perito- 
neum is involved in the tubercular deposit, and we have reason to fear 
an accession of inflammation of that membrane, there is urgent neces- 
sity for the use of topical depletion in moderation; but we must, at 
the same time, bear in mind the cachectic nature of the disease, and 
refrain from the adoption of any depressing plan of treatment. 



858 RICKETS. 

AETICLE III. 

RICKETS. 

Definition; Synonyms; Frequency. — Eickets is a constitutional dis- 
ease peculiar to childhood, which first manifests itself by various dis- 
turbances of nutrition, and later by a specific alteration in the bones. 

This disease has been known under a vast variety of names in many 
different languages;^ almost the only terms by which it is designated 
by English or American authors, however, are rickets and rachitis. 

An idea of the vast importance and frequency of this disease may be 
gained from the statements of some of the recent writers upon this 
subject. Thus Sir W. Jenner, whose lectures upon this subject {loc. cit.) 
present a most original, philosophical, and lifelike description of the 
disease, speaks of it as " without question the most common, the most 
important, and in its effects the most fatal of the diseases which exclu- 
sivel}^ affect children." Hillier, at the close of an excellent chapter 
upon rickets (Joe. cit.'), presents a table showing the proportion borne by 
the number of cases of this disease to the total numbej| of out-patients 
treated at the Hospital for Sick Children, London, from which we cal- 
culate that of 128,656 children treated during thirteen years (1854-66), 
not less than 8419, or 6.5 per cent., were rachitic; and in some years 
the proportion of such patients rose as high as 9 per cent. 

The statistics furnished by other English writers, as G-ee (loc. cit.), 
Merei, and Ritchie, support the view that in all classes of English so- 
^ciety a notable proportion of the children are rachitic. In the same 
way, the highest German authorities, as Ritter von Rittershain and 
Henoch, state that the proportion of the children treated at public 
institutions in that country, who are found to be rachitic, is not less 
than 30 per cent. 

Of late years, the attention of observers in this country has been 
more forcibly attracted to this subject, and, as a consequence, the number 
of cases in which the early and less prominent symptoms of rickets are 
now recognized is rapidly increasing. In a paper on this subject by 
Parry/ which we regard as the most valuable contribution to the lit- 
erature of rachitis which has been made on this side of the Atlantic, 
the writer states that he has been " irresistibly forced to the conclusion 
that rachitis is scarcely less frequent in Philadelphia than it is in the 
large cities of Great Britain and the Continent of Europe." We must 
add that, in our own experience, the number of cases in which we meet 
with the early, or even the more grave symptoms of rickets, is quite 
large both in private practice and in connection with public institutions. 

The fact that during the past twelve years the mortality returns of 

1 For Synonymy, see Art. Eickets in Reynolds's Syst. of Med., vol. i, p. 768. 

2 Amer. Jour, Med. Sciences, Jan. 1872, p. 17. 



CAUSES. 859 

this citY contain but two deaths reported as from rickets, is of little 
importance, since so rarely is it assigned as a cause of death even in 
Great Britain, that the Eegistrar-General has not found it necessary to 
devote a column of his tables of mortality to the disease. " The sec- 
ondary diseases," as Hillier says, "are recognized, such as bronchitis, 
collapse of the lungs, atrophy, measles, hooping-cough, or convulsions, 
but the primary disease, which renders these secondary diseases fatal, 
is ignored." 

We shall limit ourselves to an account of the causes, general symp- 
toms, and treatment of the disease, with a brief description of the ana- 
tomical changes in the bones, and the deformities which result, refer- 
ring the reader who desires more minute knowledge on these latter 
points, to any of the elaborate memoirs published on this disease.^ 

Causes. — Age. — Rickets is essentially a disease of childhood, and in- 
deed may make its appearance during early infancy. There are also a 
few cases on record which show that it may, although rarely, occur in 
the foetus before birth. It frequently may be detected during the first 
six months of extra-uterine life. Gee has noticed positive beading of 
the ribs at the third and fourth weeks, and Parry at the sixth week 
after birth. The age at which it ceases to be frequent for rachitis to 
begin is variously estimated. We have observed a number of eases 
where the earliest symptoms were detected during the second year ; 
and we should be inclined to assign as the limits of its most frequent 
occurrence the second or third month to the close of the second year. 
It grows rarer after this latter date, atid many high authorities unite in 
saying that it never comes on after the completion of the first denti- 

1 Bibliography of Rickets. — Shaw, Med.-Chir. Trans., vols, xvii and xxvi. 
Guerin, Mem. snr le Rachitis, Gaz. Med. de Paris, 1839, pp. 443, 449, 481. 
EUasser, Der weiche Hinterkopf, Stuttgart, 1843. 
Meyer, Miiller's Arch., 1849, p. 358. 

Rokitansky, Path. Anat. (Syd. Soc), 1850, vol. iii, p. 174. 
Beyhird, De Rachitis, &c. (These de Paris), 1852. 
Stiebel, in Virchow's Path. u. Ther., Bd. i, p. 527. 

Vogel, Beitrage z. Lehre v, d. Rachitis, Erhmgen, 1853 ; and Diseases of Children 
(Amer. ed., 1869), p. 520. 
Kolliker, Human Histology (Syd. Soc), 1853, vol. i, p. 352. 
Bouvier, Lect. Clin, des Malad. Chron. de I'Appar. Locom., 1856, p. 265. 
Mauthner, (Estr. Ztschr. f Kinderhlk., vol. ii, 11, 1857. 
Copland, Diet, of Pract. Med., 1858, vol. iii, p. 643. 
Eriedleben, Beitr. z. Kenntniss wachs. u. rachit. Knochen, 1860. 
Jenner, Med. Times and Gaz., 1860. 

Bouchut, Mai. des Enfants, 4eme ed., Paris, 1862, p. 825. 
G. Ritter von Rittershain, Die Path. u. Ther. der Rachitis, Berlin, 1863. 
Forster, Handb. d. Path. Anat., 2te Aufl., 1863, Bd. ii, p. 917. 
Virchow, Cellular Path. (Chance's Trans., Amer. ed.), 1863, p. 476. 
Trousseau, Clin. Med , 2eme ed., 1865, t. iii, p. 453. 
West, Dis. of Children (4th Amer. ed.), 1866, p. 588. 
W. Aitken, Art. Rickets in Reynolds's Syst. of Med., 1868, vol. i, p. 768. 
Hillier, Dis. of Child. (Amer. ed.), 1868, p. 92. 
S. Gee, St. Barth. Hosp. Rep., vol. iv, 1868, p. 69. 
Niemeyer, Pract. Med. (Amer. ed.), 1869, vol. ii, p. 507. 



860 RICKETS. 

tion in a child hitherto perfectly healthy. Considerable difference of 
opinion exists upon the question whether rickets is hereditary or not; 
but there seems no evidence to show that it ever is so, in the sense, for 
example, in which infantile syphilis is hereditary. There can, however, 
be no doubt as to the great influence exercised by the health of the 
parents upon the development of the disease. 

It is stated by some authors that too early marriages, or marriages 
between relations, and chronic tuberculosis or constitutional sj^philis of 
the father, predispose to it. These causes are, however, of doubtful 
power; and certainly are inoperative as compared with the verj'' posi- 
tive influence exercised by the condition of the mother. Thus, it is 
well ascertained, that whatever tends to induce debility and anaemia in 
the mother, as too frequent pregnancies or prolonged lactation, renders 
it probable that her next born children will be rickety. Thus, Jenner 
states that it is very common for the first, or the two or three first born 
children, to be free from an}^ sign of rickets, and j^et for every subse- 
quent child to be rickety ; which he explains by the fact, "that among 
the poor the parents are generall}^ worse fed, worse clothed, and worse 
lodged, the larger the number of their children ; and among the rich 
and poor alike, the larger the number of children, the more has the 
mother's constitutional strength been taxed, and the more likely is she 
to have lost in general power." {Loc. cit.) 

In addition to the tendency derived from the mother, there are nu- 
merous causes acting directly upon the child, which strongly predispose 
to the disease. These will be found to be nearly the same as those 
which favor the development of tuberculosis. Thus, premature wean- 
ing, and the substitution of improper food for the mother's milk: or, on 
the other hand, the continuance of suckling long after the proper period 
for weaning, and after the mother's milk has deteriorated in quality 
and become insufficient and unwholesome; or the use of indigestible, 
or of poor, scanty, and innutritious food at any period during early 
childhood, are all potent causes of rickets. So, too, many of the acute 
and chronic diseases of children, which impair assimilation and nutri- 
tion, as entero-colitis; and all such depressing influences as impure 
water, foul air, poor ventilation, small, damp, and dirty habitations, 
may be classed among the predisposing causes. 

The marked alterations and deformities of the bones, which are so 
characteristic of rickets, are not developed until after a more or less 
marked cachectic state of system has persisted for a time, varying from 
a few weeks to several months. 

During this initiator^" stage, the most marked symptoms are con- 
nected with the digestive s^^stem. The appetite may remain good or 
grow capricious ; and the bowels are irregular, though for the most 
part of the time there is diarrhoea, with stools which are at first green- 
ish and mucous, subsequently serous, w^aterj^, of a brownish or slate 
color, and horribly offensive. If this chronic intestinal catarrh be but 
slightly marked, the child may retain a good deal of its fat, though fre- 
quently there is extreme emaciation. 



SYMPTOMS OF STAGE OF INVASION. 861 

The head is frequently bathed in profuse perspiration, which occurs 
especially during sleep, but also after any exertion, or even while the 
child is \ying quiet. The skin of the trunk and extremities is hot and 
dry, and even the lightest covering seems oppressive to the little pa- 
tient ; so that there is a tendency to get rid of all the bed-clothing at 
night. 

Another symptom which makes its appearance in a certain propor- 
tion of cases, but not so constantly as the digestive disturbances, local 
sweatings, and restlessness at night, is general soreness and tenderness 
of the body, with pain on movement : w^hen this is marked, the child 
dreads to be moved or even touched, cries if its limbs be pressed firmly, 
and will lie almost motionless for hours. According to Parry (loc. cit.), 
this symptom is associated with the commencing bone changes, so that 
it properly belongs to the early part of the second stage. 

If the disease begins before the completion of primary dentition, the 
development of the teeth is always impeded, and they are not only cut 
late, but either decay or fall very earl}^ from their sockets. The urine 
does not present any constant alteration, but in a certain proportion of 
cases the amount is increased, and there is an excess of the phosphatic 
salts, while in other instances excess of some free acid, said to be 
usually lactic, has been detected. The mental condition in rickets has 
been variously described; some authors regarding the intelligence as 
precocious, owing probably to the isolation of the patient from other 
children, and his constant association with his elders; while others 
assert that there is an actual deficiency in intellectual capacity and 
power. At a somewhat later period of the disease, the child acquires a 
peculiar staid and sedate aspect, which, when associated with the 
unusual breadth and squareness of the face, imparts a strange expres- 
sion of age. 

According to Eoger and Eilliet, a blowing murmur may frequently 
be heard over the anterior fontauelle in this disease, synchronous with 
the arterial pulse. As, however, this murmur is to be heard in other 
conditions, and is often absent in cases of rickets, it cannot be consid- 
ered as a sign of any positive value. The causes which appear to in- 
tensify it, are the ansemic state of the blood and the patency of the 
anterior fontanelie ; yet Hillier states that he has found it present in 
thirteen, and absent in twenty-nine rickety children whose fontanelles 
were open. 

The phenomena above described, when present in the same case, may 
certainly be regarded as positively indicative of the existence of this 
initiatory stage of rickets, but they are b}^ no means invariably all 
present, so that it is often impossible to determine the approach of the 
next stage in which the characteristic lesions and deformities of the 
bones make their appearance. 

They are not, moreover, limited to the stage of invasion, but continue, 
with more or less severity, for a varying time after the bone-changes 
have begun. The length of this stage of invasion is exceedingly irregu- 
lar, and the earliest physical signs of bone-change may occur after it has 



862 RICKETS. 

lasted a few weeks, or may be deferred for several months after the 
peculiar prodromic sj-mptoms have been marked. 

Stage of Deformity. — After the initiatory stage has lasted for a vary- 
ing time, swellings begin to be noticed at the line of junction of the 
ribs and costal cartilages, which is usually regarded as the earliest 
lesion of the bones, and of the epiphyses and shafts of the long bones 
of the upper and lower extremities, giving in these latter places, as at 
the ankles and wrists, a peculiar knobby double-jointed appearance. 
With this, there is such a degree of softening of the bones, that they 
yield readily to pressure. 

Early in this stage the presence of craniotabes, or "soft spots" in 
the occipital bone, may often be detected. Indeed, in some instances 
this appears to be the first recognizable bone lesion. 

If the disease reaches this stage- before the child has begun to walk, 
there may be no deformity of the lower extremities whatever; but in 
cases where the little patient has already been walking about, the fem- 
ora bend so that they become markedly convex forwards; the tibiae 
bend in the same forward direction, while the knees may be bent in- 
wards, thus giving to the legs a series of curvatures. The forward 
curvature of the femora may indeed be produced before the child walks, 
simply by the weight of the legs and feet, which hang pendent from 
the knee-joints as the child sits in its mother's lap or on a chair. 

The bones of the upper extremities also share in these deformities; 
thus the humeri bend at the point of insertion of the deltoids, from the 
weight of the arms when raised by the action of these muscles; and 
both the humeri and the bones of the forearms become bent, from the 
pressure which the child makes on its open palms to assist itself in sit- 
ting up. 

The clavicles are very constantly deformed, and present a double 
curvature; one curve being forwards and somewhat upwards, and 
seated just outside of the attachment of the sterno-cleido-mastoid 
muscle, the other being backwards, and seated about half an inch from 
the acromio-clavicular articulation. 

By far the most important deformities, however, are those presented 
by the head, spine, thorax, and pelvis. The peculiarities by which the 
head in rickets is distinguished, are thus described by Jenner: 

1st. By the length of time the anterior fontanelle remains open. 
In the healthy child, it closes completely before the expiration of the 
second year. In the rickety child, it is often widely open at that 
period. 

2d. By thickening of the bones. This is usually most perceptible 
just outside the sutures, the situation of the sutures being indicated by 
deep furrows. 

3d. By the relative length of the antero-posterior diameter of the 
head. 

4th. By the height, squareness, and projection of the forehead. The 
first two of these peculiarities of the rickety head are the result of the 



CAUSES. 863 

affection of the bones; the last two are due chiefly to disease of the 
cerebrum. 

Besides this thickening of the edges of the cranial bones, there are 
spots, irregularly distributed, where the bones are so thinned and soft- 
ened that they yield to the pressure of the fingers; and, indeed, in some 
cases the thinning is so extreme that the pericranium and dura mater 
come in contact. These " soft spots," which constitute the condition 
known as craniotabes, w^ere first observed by Elsasser (Joe. cit.). 

The nature and mode of their production has been a matter of much 
discussion. By some authorities their rachitic nature has been denied, 
but there seems to us no valid reason for doubting their essential con- 
nection with the rachitic alterations of the bones. They are usually 
limited to tbe occipital region, but may rarely be present over the other 
cranial bones. They are never observable save in those parts of the 
bones wbich are developed from membrane. At first, the spots affected 
are the seat merely of softening, with perhaps some thickening; then 
thinning of the bone occurs, and subsequently the entire thickness of 
the occipital bone is often removed, causing perforations. These vary in 
number from one or two to as many as twenty-five or thirty. In order 
to detect them, the skull should be carefully examined by fixing the 
head between the hands, and then pressing carefully over the upper 
part of the occipital region and the posterior portions of the parietal 
bones. The diseased spots are felt to be soft and easily depressed, and 
"impart the sensation of an orifice in the bone, closed by parchment.'' 
It is necessary to use much caution and gentleness in making this ex- 
amination, since any undue pressure may produce severe nervous 
symptoms, even convulsions, according to Niemeyer. It is difficult to 
account for the production of these spots, but the most probable expla- 
nation is that they are dependent upon the prolonged pressure upon 
the softened bone, caused by the head resting on the pillow on one 
side, and by the counter-pressure of the brain on the skull on the other. 

The curvature of the spine varies according as the child is able or 
unable to walk. In the latter case, there is a posterior curvature of the 
spine, beginning at the first dorsal, and extending to the last lumbar 
vertebra; while if the child is able to walk, this posterior curvature is 
limited to the dorsal region, but is combined with an anterior curva- 
ture in the lumbar region. The cervical anterior curve is increased, 
and consequently the face is directed upwards, and the head falls back- 
wards, and being unsupported, owing to the muscular debility, sways 
looselj^ from side to side. Jenner points out that these curvatures may 
readily be distinguished from angular curvature, by the fact that the 
weight of the legs will usually remove them if the child be held by the 
upper part of the trunk, especially if the physician at the same time 
raises the lower limbs with one hand, and places the other on the 
curved spine. 

The thorax is subject to deformities, which in a practical sense ex- 
ceed all others in importance, owing to the serious interference which 
they occasion with the action of the heart and lungs. 



864 RICKETS. 

In the first place, owing to the curvature of the spine, the ribs are 
flattened laterally, and run forwards more horizontally, so that the lat- 
eral diameter of the chest is greatly diminished, while the sternum is 
carried forwards, and thus the antero-posterior diameter of the thorax 
is increased. In addition, there is a marked groove on either side of 
the sternum, extending from the first to the ninth or tenth ribs, along 
the line of junction of the ribs with their cartilages. These grooves 
are produced by the bending of the ribs where the dorsal and lateral 
portions unite; from which point they pass forwards and inwards to 
unite with their cartilages, which curve outwards before uniting with 
the sternum. 

The curvatures and deformities which have been described before 
this are chieflj^ due to the action of muscles or the weight of depend- 
ent parts; but the production of the last-described deformities of the 
thorax is attributed by Jenner chiefly to the atmospheric pressure, 
Avhich, during inspiration, causes recession of the most yielding part 
of the thoracic walls, i. e., the softened ribs at the line of junction 
with their cartilages. In consequence of the support which the liver, 
heart, and spleen furnish to the ribs corresponding to their position, 
the groove extends further down on the left than on the right side, 
but is deeper over the fifth and sixth ribs on the right than on the left 
side. 

The pelvis is frequently affected in rickets, and the deformities which 
result, on account of the great interference they cause in childbirth in 
the female, rank next in importance to those of the thorax. The rick- 
ety pelvis is characterized by a shortening of the antero-posterior di- 
ameter, so that the. upper strait assumes an oval form, or is at times 
heart-shaped. In extreme instances the sides also approximate, and 
give to the pelvis a triangular shape. It is evident that the form will 
be influenced by a number of conditions; as the stage of ossification, 
and the direction in which the pelvis is compressed by the spine from 
above, and the thigh-bones from below. 

Partly in consequence of tiie diminished capacity of the thorax and 
pelvis, partly in consequence of the weakness of the abdominal mus- 
cles, the flatulent distension of the intestines, and the enlargement of 
the liver and spleen which are frequently present, the abdomen is un- 
usually prominent in rickety children. 

During the development of the alterations in the bones, the general 
symptoms before described persist; the digestion is enfeebled, and the 
stools liquid and fetid; the emaciation and debilitj' increase; the res- 
piration is more or less embarrassed by the deformities of the thorax; 
the pulse is quick, small, and irritable; the skin hot, excepting on the 
head and neck, where it is still frequently bathed in sweat; and the 
general tenderness of the body is aggravated. 

In cases where the disease approaches a favorable termination, the 
earliest signs of improvement consist in a decrease in the emaciation, 
debility, and suffering; the stools become more healthy, and the febrile 
symptoms, if any have been present, disapjDear. 



DURATION — PROGNOSIS — DIAGNOSIS. 865 

During this stage of early convalescence, -when the children attempt 
to leave the bed and walk about, holding on to the chairs, there is great 
danger of increased curvature and even of partial fractures of the bones 
of the lower extremities. 

When, on the other hand, death occurs during the course of rickets, 
it is rarely from the intensity of the cachexia (which explains the ap- 
parent anomaly of so fatal a disease being scarcely represented in the 
mortality returns), but from the supervention of some secondary dis- 
ease. Among these, the following are enumerated by Jenner as the 
most frequent causes of death : 

1. Catarrh and bronchitis, which are rendered far more dangerous 
from the mechanical interference with respiration caused by the de- 
formed thorax. 

2. Albuminoid (?) infiltration of various organs, especially of the 
liver, spleen, and lymphatic glands. As vi'iW be seen by the remarks in 
the section on morbid anatomy, recent researches make it probable 
that the enlargement of these organs in rickets differs from ordinary 
albuminoid change. This peculiar form of degeneration is not unfre- 
quently developed during the course of rickets; it manifests itself by 
increased emaciation, extreme pallor, occasional oedema and albumi- 
nuria, and enlargement of the affected organs. 

3. Laryngismus stridulus, which, according to Jenner, is essentially 
connected rather with the nervous irritability due to rickets, than w^ith 
the tardy and difficult dentition which is itself but another expression 
of the constitutional disease. 

4. Chronic hydrocephalus. 

5. Convulsions, depending like the laryngismus stridulus, upon the 
heightened irritability of the nervous system. 

6. Persistent and severe diarrhoea, which is probably due in many 
cases to albuminoid degeneration of the intestinal mucous membrane. 

Duration; Prognosis. — The duration of rickets varies so greatly, 
that the disease may be said to present an acute and chronic form. 

When the diathesis is marked, the hygienic conditions of the child 
very unfavorable, and the disease makes its a^^pearance at an early age, 
its course is often very rapid, and death usually follows. When, on 
the other hand, the disease does not begin till late in the second or third 
year, and when the surroundings of the child are more favorable, re- 
covery usually occurs, although the disease may last for several 3^ears. 

An unfavorable prognosis may be made, then, when the disease be- 
gins in very early infancy; when it is attended with marked constitu- 
tional disturbances; when the deformities of the head and thorax are 
rapidly and extremely developed; when any of the secondary morbid 
conditions above enumerated have supervened. When, on the other 
hand, the reverse of these conditions obtains, recovery may be ex- 
pected, though often only after prolonged illness. 

Diagnosis. — It is only during the initiatory stage of rickets, that the 
true nature of the attack is likely to be mistaken. But during this 
period the disease may be confounded either with chronic entero-colitis, 

55 



866 RICKETS. 

or with tuberculosis of the peritoneum and intestinal canal. Careful 
attention to the peculiar symptoms of rickets, especially the sweating 
of the head, the general soreness and tenderness of the body, and the 
retardation of dentition, will, however, lead to a correct diagnosis, 
even before the swelling of the sternal ends of the ribs and of the epi- 
physial lines of the long bones, and the projection of the sternum, re- 
move all doubt as to the nature of the case. 

Morbid Anatomy The essential lesions in rickets consist of the 

changes in the bones, though there are also certain lesions of the vis- 
cera which are frequently met with. 

The long bones affected by rickets, in addition to the deformities 
already described, are clumsy, and present marked swellings at the line 
of their junction with the epiphyses. This enlargement is due to ex- 
cessive development of the spongy tissue in the extremity of the bone 
xind the epiphysis, and to marked proliferation of the epiphysial carti- 
lage. The fact that the epiphyses widen instead of elongating, is due 
to the pressure of the superimposed parts upon the soft proliferating 
layers, causing them to bulge laterally. 

The deposition of calcareous granular particles at the line of ossifi- 
cation is also wanting, and the cartilage-cells calcify before the matrix 
begins to ossify, and are converted into bone-cells. 

There is thus excessive formation of the structures which precede or 
form the nidus for ossification, while there is at the same time retarda- 
tion or incomplete performance of that process. 

At the same time, the diaphyses present rarefaction of their tissue, 
not owing to undue softening and removal of old bone, but simply to 
the fact that, while the old layers of bone are consumed by the nor- 
mally progressive formation of medullary cavities, the new layers which 
are produced are soft and do not ossify. 

The medullary space may reach the line of ossifi^cation, or even pro- 
ject beyond it into the proliferating epiphysial cartilage. 

The periosteum of rickety bones is usually thickened and highly vas- 
cular. 

The bones themselves become so soft that they may be bent in any 
direction, or even cut with a knife without difficulty. 

Upon section the spongy tissue and the enlarged areolae are found 
filled with a crimson pulp, containing blood-globules, a large amount of 
free fat in some cases, and very manj^ round, faintly granular cells, 
with one or two nuclei. According to Hillier and Parry the reaction 
of rachitic bones is alkaline or neutral. 

The softening of the bones is fully accounted for by the diminution 
in the proportion of their calcareous salts. Thus Jenner states as the 
mean of the analyses of several observers, that the bones of healthy 
children, yield about thirty-seven parts of organic and sixty-three of 
inorganic matters; whereas those of ricket}^ children yield about 
seventy-nine parts of organic to twenty-one parts of inorganic matters. 
In addition to this, it would appear that the organic matters themselves 
undergo change, since it has been found by several experimenters that 



MORBID ANATOMY. 867 

the bones in advanced rickets yield neither chondrin nor gelatin on 
boiling. 

The thickening of the flat bones is caused by the formation of new- 
osseous layers from the thickened and vascular periosteum, which are 
formed at or near the growing margins of the bones, thus accounting 
for the thickened ridges near the sutures of the cranial bones. 

The deo-ree of thickening of the bones of the skull may reach a very 
high degree; a thickness of i" having been quite frequently observed. 
There are also frequently found on the skull evidences of craniotabes 
in the form of round or oval perforations of the bone, which have been 
observable during life as "soft spots.^' These perforations are most 
constant and frequent in the occipital bone, and are also found in the 
parietal bones, or wherever the skull has been subjected to pressure. 
They are surrounded by thickened bone, and are produced by the re- 
sorption of the calcareous salts, under the influence of pressure, while 
the thickened bone is still soft and imperfectly ossified. In number 
they vary from one to twenty or thirty. 

In addition to these changes in the bones, which are the constant 
and essential lesions in rickets, there are certain lesions of the viscera 
frequently met with, which depend partly upon the deformities of the 
skeleton and partly upon the general cachexia. Thus, in consequence 
of the peculiar deformity of the thorax, the anterior borders of the 
lungs become highly emphysematous, while the band of lung-tissue 
corresponding to the deep groove at the sternal end of the ribs is com- 
pressed and collapsed. 

This peculiar and constantly present strip of collapsed lung, is due 
to the recession of the corresponding part of the ribs during inspira- 
tion ; but frequently there is also found extensive collapse of the postero- 
inferior parts of the lungs from the ordinary causes, bronchitis and 
impeded respiration. Jenner has also called attention to the frequent 
presence in rickets of white spots upon the pericardium, near the apex 
of the heart. These spots thus correspond to the depressed part of the 
fifth left rib, and are in all probability due to the friction of the heart 
against this hard knuckle of bone. 

We have before alluded to the enlargement of the liver and spleen 
which appears in some severe cases of rickets. This was formerly re- 
garded as due to albuminoid degeneration, but recent study of such 
organs has made it probable that the alteration is a peculiar and spe- 
cific one. 

The differences between this change, and albuminoid (amyloid, of Yir- 
chow) degeneration were first pointed out by Jenner,^ who showed that 
in the rickety enlargement, the organs present no reaction with iodine, 
and that in the spleen there is an absence of the peculiar sago-like trans- 
formation of the Malpighian corpuscles. Dr. W. H. Dickinson has 
more recently examined this subject with care, and has confirmed the 
view that the change in rickets differs both from albuminoid degeneration 

1 Medico-Chir. Trans., vol. lii, 1869, p. 359, 



868 RICKETS. 

and from the peculiar enlargement of the spleen and lymphatic glands 
known as Hodgkin's disease. The liver in rickets undergoes an increase 
of size evenly throughout its whole bulk: it becomes pale, containing 
little blood, and is less friable than in health, hard, dense, and elastic. 
The acini are yellowish and are surrounded by a pinkish or grayish 
line, due to increase of the interlobular connective tissue. There is 
not, however, any bacony translucency as in albuminoid degeneration. 
The spleen is even more markedly enlarged than the liver, so that its 
weight may increase from one ounce to half a pound. The organ pre- 
sents a resilient hardness which in extreme cases was compared by 
Bright to the consistence of a half-ripe apple. The color is generally 
a deep-red or purple, besprinkled with smooth white spots, which are 
enlarged Malpighian corpuscles. The trabecule are much thickened, 
and there may be also morbid hyperplasia of the cellular contents of 
the meshes, the corpuscles being much crowded together. The above 
change is described by Dickinson, as due not to the presence of any 
formation foreign to the structure of these organs, but to an irregu- 
larity of growth which alters the natural proportions of their tissues. 
The epithelial and corpuscular element is generally increased, while in 
the liver the capsule of Glisson, and in the spleen the trabecular tissue, 
is abnormall}^ developed. There would appear also to be a deficiency 
of earthy salts in these organs. 

In cases where death is directly due to any secondary disease, as 
bronchitis, intestinal catarrh, or chronic hydrocephalus, there will of 
course be found, in addition, the lesions common to such affections. 

Pathology. — The description which has been given of the symptoms 
of rickets, clearly establishes the fact that it is a constitutional disease, 
in the same sense that scrofula and tuberculosis are ; and we are conse- 
quently to regard the lesions of the bones as merely a local manifesta- 
tion of the general cachexia. We are unable, however, to advance 
beyond this point, since we are ignorant, not only of the essential 
nature of the vice of nutrition, but equally so of the specific nature of 
the changes in the bones. 

The result of chemical analysis has led to the theory that the disease 
essentially consists in a deficiency of the calcareous salts of the bones ; 
and the attempt has been made to explain this deficiency by supposing 
an excess of lactic acid in the primes vise and blood, which holds the 
calcareous salts in solution, and prevents them from being deposited in 
the bones. Apart from the parety hj-pothetical nature of this supposi- 
tion, and its entire inadequacy to explain many of the most serious 
symptoms of rickets, it is to be borne in mind that the excess of free 
acid in the urine is far from being constant, and that the changes in the 
bones are characterized not merely by a deficient deposit of the cal- 
careous salts, but by their abnormal position, and by all the evidences 
of an active vital process. 

Again, the marked vascularity of the bone and periosteum, the rapid 
proliferation of cells, and the pain and constitutional irritation which 
attend the disease, have induced others to regard the process as an in- 



TREATMENT. 869 

flamraatory one. Bat this view is controverted as well by the etiology 
and clinical history of the disease as by its constant anatomical results. 

Treatment. — In cases where there is reason to anticipate the devel- 
opment of rickets, as where the previous children of the mother have 
become rickety, the utmost attention must be paid to the feeding and 
hygiene of the young infant. If careful examination of the mother's 
milk proves that it is unsuitable in quality, a wet-nurse should be im- 
mediately provided, or if that be unattainable, the child should be fed 
upon carefully selected cow's milk, or upon one of the substitutes for 
human milk described in the article on thrush. 

So too, after the disease has made its appearance, the most appro- 
priate, nutritious, and digestible diet must be. selected, care being taken 
that it shall contain a large proportion of animal food. 

The teeth of rickety children are so defective that, when they begin 
to take solid food, it is highly necessary to insure its complete mastica- 
tion, and in cases where the condition of the teeth renders this impos- 
sible, the meat should be chopped finely and bruised in a mortar. 

The child should be suitably and warmly dressed, and be taken freely 
into the sunlight and open air. The use of salt-water baths, followed 
by active friction of the skin, is also to be recommended. 

During the early stage, when there is marked constitutional irrita- 
tion and pain, the remedies used to relieve these symptoms should be 
alkaline mixtures, such as the effervescing draught or neutral mix- 
ture, or magnesia (Copland), conjoined with sedatives and tonics. 
Under no circumstances should any depressing plan of treatment be 
adopted. 

If the digestion be much impaired and diarrhoea is present, the use 
of vegetable tonics, or wine of iron, with mild astringents and antacids, 
is indicated. 

The remedy, however, from which most benefit is usually derived is 
cod-liver oil, and it should consequently be given, in conjunction with 
iron and vegetable tonics and a small amount of some generous wine, 
so soon as the nature of the attack is recognized and persevered with 
for months, or until the disease is overcome. 

The eflScacy of cod-liver oil in the treatment of this disease is, indeed, 
so remarkable that all other remedies formerly used have been sup- 
planted by it. Yogel asserts (o/>. cit., p. 534) that " rachitis may be 
cured by the use of cod-liver oil alone, even if the circumstances are in 
other respects unfavorable." Eickety children usually tolerate the oil 
well, and even become so fond of it that they will willingly take large 
doses. In some cases, however, it disagrees with the stomach and is 
obstinately refused by the children ; and when this happens, so im- 
portant is the introduction of the oil into the system, that we should 
recommend its use by inunction. It very rarely happens, however, 
that the difficulty in its administration cannot be overcome \>j having 
the oil prepared in the form of an emulsion, either according to the for- 
mula recommended on page 366, or in combination with the lacto-phos- 
phate of lime. 



870 CONGENITAL SYPHILIS. 

There can be no doubt that when rickets is recognized in its early 
stages, and a suitable medicinal and hygienic treatment promptly in- 
stituted, it is usually curable in a comparatively short time. When, 
however, the diathesis is strong and the case overlooked until soften- 
ing of the bones has occurred, and deformities begin to appear, the 
treatment must be persisted in for many months or even years. In 
such cases, unfortunatelj^, there is only too great probability of the de- 
formities increasing and becoming permanent, even if death does not 
ensue from some intercurrent or superinduced disease. 

In order to guard against deformities, the little patient should lie 
upon a firm, smooth mattress, and high pillows should be forbidden, 
^iemeyer recommends that small children should be carried out in a 
basket; while larger ones should be drawn about in a carriage pro- 
vided with a mattress. Sitting up for any length of time^ or attempts 
at walking, should be prohibited until the bones have grown firm and 
inflexible. 

It is not advisable, especially during the earlier stages of the disease, 
to emplo}" any mechanical contrivances to prevent or relieve deformi- 
ties. During convalescence, however, attempts may be made to control 
the deformities by means of leather or pasteboard splints. 

In the treatment of any intercurrent affections it must be remem- 
bered that we have to do with a condition of malnutrition and enfee- 
bled vitality, so that all remedies of a depressing character must be 
scrupulously avoided. 



AETICLE ly. 



CONGENITAL SYPHILIS. 



Infantile syphilis may be either inherited or acquired subsequent to 
birth. As, however, the characters of the latter form do not differ 
materially from those of acquired syphilis in the adult, we shall limit 
our description to hereditary syphilis. 

Careful clinical observation appears to have clearly demonstrated the 
following facts with regard to the transmission of syphilis, in addition 
to the direct contagiousness of both the primary and secondary mani- 
festations : 

That the embryo in utero may be infected, if either of the parents 
have constitutional syphilis at the period of conception, no matter 
whether the disease be latent, or if secondary or tertiary symptoms are 
present. That if both parents are syphilitic the child will more surely 
suffer from the disease, and in a more severe form. That if the mother, 
though health}^ at the time of conception, contract syphilis during the 
first six or seven months of pregnancy, the child will probably be in- 
fected. That when the mother infects the embryo, the disease is prob- 



SYMPTOMS. 871 

nblv more severe than when the father alone is syphilitic, and thus 
such embrvos usually perish, and are prematurely cast off by abortion, 
80 that the great majority of children with congenital syphilis have in- 
herited it from their father. While the last statement is almost uni- 
versally admitted, there are some authors, as Hutchinson,^ who do not 
admit the greater severit}' of the disease when the mother is the source 
of contagion. Finally, that a syphilitic father may infect the ovum 
without contaminating the mother's system, though the mother may 
subsequently herself be infected by the embryo. 

In very many cases, though unfortunately not in all, the infected 
embrj'O perishes, and abortion follows. When, however, such infants 
are born living, they usually present no trace of syphilitic disease at 
birth, but may appear well nourished and healthy. Occasionally, how- 
ever, children have been observed who presented, at the time of birth, 
copper-colored blotches upon the skin, condylomata, or mucous patches. 

In the majority of cases the first symptoms of the disease appear be- 
tween the fifteenth and thirtieth days after birth, though in many in- 
stances also during the second month. Thus of 158 cases collected 
from various sources by Diday,^ the disease showed itself — 

Daring 1st month in 86 

" 2d *" 45 

" 3d " 15 

At 4th month in 7 

" 5th " 1 ■ 

" 6th " 1 

" 8th " 1 

" 1 year, 1 

" 2 years, 1 

So that 131 children out of 158 presented evident symptonrfs of syphi- 
lis before the end of the second month. 

Among the earliest evidences of the disease are the signs of failing 
nutrition. The infant, who has grown well, and has been plump and 
apparently vigorous for a few weeks, begins to emaciate, the features 
become pinched, the skin assumes a dry, sallow, shrivelled appearance, 
and presents patches of yellowish-brown discoloration, especially on 
the prominent parts of the face; the voice becomes feeble, whimpering, 
and plaintive, and the infant soon acquires a remarkable expression of 
premature old age. 

The appearance of the skin has been most minutely described by 
Trousseau,^ West,* Diday, and others, and is in a high degree charac- 
teristic of the disease. 

In addition, however, to these general symptoms of malnutrition, 
there soon appear the signs of constitutional syphilis, familiarly met 

1 Art. Constitutional Syphilis, in Reynolds's Syst. of Med , vol. i, pp. 297 and 315. 

2 Infantile Syphilis (Syd. Soc), 1859. 

3 Clin. Med , 2emeed., 1865, t. iii, p. 291. 

4 Dis. of Children (4th Am. ed.), 1866, p. 577. 



872 CONGENITAL SYPHILIS. 

with in the adult, as well as some which are peculiar to the disease in 
infancy. 

The symptoms now to be described belong partly to the secondary 
and partly to the tertiary stage, for it is a peculiarity of infantile syphi- 
lis that the evolution of the symptoms does not follow so orderly a 
course as in syphilis of the adult. The symptoms most frequently met 
with are certain affections of the skin and mucous membranes. Among 
the cutaneous eruptions, pemphigus is one of the most characteristic. 
It is also the first eruption to appear, not rarely being present at birth, 
and never, according to Niemeyer,^ commencing later than the end of 
the first week of life. 

It usually appears first on the palms of the hands and soles of the 
feet, and may afterwards spread to various parts of the surface. It be- 
gins as small round spots, of reddish color, which become converted in 
a dixy or two into bullse, filled with turbid fluid. These burst, leaving 
irritable excoriations, and are succeeded by fresh crops of similar vesi- 
cles. The early appearance of pemphigus is of most fatal import; 
though in some cases recovery gradually occurs in the course of a few 
weeks. The other forms of eruption usually occur after the general 
sj^nptoms of malnutrition, above described, have appeared. At times 
the eruption consists of sharply defined patches of roseola or erythema 
of small size, of coppery or yellowish-red color, not disappearing upon 
pressure, and occurring usually upon the abdomen, the inner surface of 
the thighs, or the lower part of the thorax. 

In other cases, the eruption assumes a papulated form, the papules 
being quite prominent, and usually presenting a superficial desquama- 
tion. A form of acne, attended with the appearance of indurated pus- 
tules which leave little depressed cicatrices, is not unfrequently met 
with; and so, also, vesicular and pustular eruptions occur in a good 
many cases. The most frequent of these eruptions is unquestionably 
the maculated form; while dry, scaly eruptions are in particular quite 
rare in infantile syphilis. In most cases the specific character of the 
eruption is manifested b}^ the peculiar coppery color of the macula, or 
of the inflamed base of the papule, vesicle, or pustule. In other in- 
stances the specific character of the eruption must be inferred from the 
coexistence of other manifestations of constitutional syphilis. 

The most frequent of these, next to the cutaneous eruptions, are the 
affections of the mucous membranes. Thus, coryza, of a serious and 
most obstinate form, is one of the most constant sj^mptoms met with, 
and presents here all the characters fully described in our article upon 
that subject. The nasal mucous membrane is so much swollen that 
breathing and nursing are seriously interfered with. There is a pro- 
fuse discharge from the nostrils, either of a thin, irritating fluid, which 
flows over the lip and excoriates it, or of a thicker pus, which tends to 
concrete and form thick, discolored crusts. The obstruction to respi- 

1 Textbook of Pract. Med. (Am. trans.), 1869, vol. ii, p. 706. 



SYMPTOMS. 873 

ration, and the accumulation of secretion in the nasal cavities, gives 
rise to a peculiar snorting or snuffling quite characteristic of the disease. 

There is apt to be, at the same time, a superficial diffuse inflamma- 
tion of the mucous membrane of the mouth and throat, which may ex- 
tend into the larynx, causing, in conjunction with the coryza, great 
alteration in the cry or voice, which is hoarse, and has been under 
such conditions compared by West to the sound of a child's penny 
trumpet. 

Despite the severity and obstinacy of the coryza, there very rarely 
occurs any ulceration of the mucous membrane, or necrosis of the nasal 
bones, or of the hard palate. In a few cases, however, depression of 
the bridge of the nose has been observed in consequence of the destruc- 
tion of the nasal bones, and West records a case in which there was 
necrosis of the hard palate in a young infant. 

Another very frequent symptom is the formation of rhagades or fis- 
sures at the junction of the mucous membranes and skin, as on the lips, 
and at the verge of the anus. These rhagades bleed upon any stretching 
of the parts, and by their laceration so much pain is caused that, when 
the mouth is affected, the child dreads to smile, talk, or suckle; and 
when they are seated on the anus, defecation is attended with extreme 
suffering. Occasionally rhagades form in the skin in the flexures of the 
joints, and especially in those of the fingers and toes. 

Condylomata are also frequently present, and, like the rhagades, are 
most frequent at the orifice of the anus and mouth, though they may 
also form elsewhere upon the skin, as upon the vulva, between the scro- 
tum and thighs, in the axillae, and behind the ears. 

In consequence, probably, of the softening and ulceration of these 
growths, large, sinuous, irregular ulcers may form in such positions, 
extending for some distance into the surrounding skin. 

In a few cases, iritis occurs; and so too the deeper seated tissues of 
the globe, as the vitreous humor, retina, or choroid, may become in- 
flamed. 

Death very frequently ensues before the end of the first year, either 
in consequence of the severity of the coryza and the inability to nour- 
ish the little patient, or in consequence of the profound cachexia and 
ansemia, or the development of some of the visceral lesions, to be here- 
after described. When, however, owing to judicious treatment, or the 
comparatively slight development of the early symptoms, the child sur- 
vives, the disease frequently subsides about the end of the first year; 
but often, after remaining latent for a variable time, reappears in the 
form of tertiary symptoms. According to Hutchinson, this tertiary 
epoch may begin at any period after the fifth year, but is commonly 
delayed till at or near the period of puberty. In addition to the traces 
which may remain of the earlier symptoms, such as little pits and scars 
upon the skin, alterations in the form of the nose from long-standing 
nasal obstruction, or actual disease of the nasal bones, there are several 
very characteristic symptoms amongst the later manifestations. 

Among these is a peculiar alteration of the permanent incisor teeth, 



874 CONGENITAL SYPHILIS. 

;6rst described by Mr. Jonathan Hutchinson. Although we are not alto- 
gether disposed to attach the overpowering weight which Mr. Hutch- 
inson does to the evidence furnished by this alteration of the teeth, of 
the existence of inherited syphilis, there is no doubt that it is an im- 
portant sign, and we, therefore, quote in full his description of it (loc. 
cit, p. 317): 

"In these patients (those suffering with inherited syphilis), it is very 
common to find all the incisor teeth dwarfed and malformed. Some- 
times the canines are affected also. These teeth are narrow and rounded, 
and peg-like; their edges are jagged and notched. Owing to their 
smallness, their sides do not touch, and interspaces are left. It is, how- 
ever, the upper central incisors which are the most reliable for purposes 
of diagnosis. When the other teeth are affected these very rarely escape, 
and ver}^ often they are malformed when all the others are of fairly 
good shape. The characteristic malformation of the upper central in- 
cisors consists in a dwarfing of the tooth, which is usually both narrow 
and short, and in the atrophy of its middle lobe. This atrophy leaves 
a single broad notch (vertical) in the edge of the tooth, and sometimes 
from this notch a shallow furrow passes upwards on both the anterior 
and posterior surface nearlj^ to the gum. This notching is usually sym- 
metrical. It may vary much in degree in different cases; sometimes 
the teeth diverge, and at others they slant towards each other. In 
a few rare cases, only one of the upper central incisors is malformed, 
the other being of natural shape and size. It is only in the permanent 
set that such peculiarities are to be observed; the first set are liable to 
premature decay, but are not malformed." 

Another valuable symptom of inherited syphilis at this stage, and 
one which never occurs in acquired syphilis, is a peculiar form of kera- 
titis, or inflammation of the cornea, which has been termed interstitial 
or syphilitic. It also is usually symmetrical, and is attended by opacity 
of the cornese from the formation of lymph in their substance. The 
inflammation usually subsides in a few weeks or months, leaving slight 
cloudy opacities here and there in the substance of the cornea. 

Occasionally also there are symptoms indicative of grave visceral 
disease. The liver and spleen may be found enlarged and firm, and in 
such cases ascites is not rare. So, too, affections of the nervous system, 
usually limited to a single pair of cerebral nerves, as the auditory, and 
causing deafness, or the optic, and causing amaurosis, are met with in 
some instances. 

Even now marked disease of the bones is rare, though nodes quite 
frequently form upon the long bones ; and, in some few cases, the disease 
breaks out in the form of destructive lupus, or of serious disease of the 
bony tissues. 

Morbid Anatomy. — The principal lesions found in the victims of in- 
herited syphilis, are in connection with the liver and lungs; more rarely 
other organs, as the brain or thymus gland, present evidences of dis- 
ease. The liver is at times enlarged, rounded, and indurated, appar- 
ently the result of diffuse subacute hepatitis, or of infiltration of the 



DIAGNOSIS — PROGNOSIS. 875 

organ with the peculiar albuminoid substance, called " amyloid," by 
Tirchow. It is comparatively rare in children to find gummy tumors 
developed in the substance of the liver, with thickening and cicatricial 
puckering of the capsule, as are so often met with in visceral syphilis 
in adult life. 

In the lungs, gummy tumors of various sizes form, and usually pre- 
sent cheesy degeneration of their central portion; and there is at times 
also a form of consolidation, called by "Virchow "white hepatization," 
which depends upon chronic catarrhal pneumonia, with infarction of 
the air-vesicles with epithelial cells, in a state of partial cheesy degen- 
eration. 

More rarely, gummy tumors have been found in the substance of the 
brain. The thymus gland is occasionally the seat of suppurative in- 
flammation, so that, on section, abscesses may be detected in the sub- 
stance of the organ. Of course in cases where periostitis, with the 
formation of nodes, has been present, the ordinary appearances of such 
lesions will be observed. 

Diagnosis. — During the presence of the early symptoms, the diag- 
nosis is usually made with ease, by observing the presence of pemphigus 
soon after birth ; of other eruptions, with copper-colored discoloration 
of the skin, appearing a few weeks later; of condylomata and rhag- 
ades ; and of coryza, stomatitis, and laryngitis. The general symp- 
toms are also peculiar, especially the physiognomy and the discoloration 
of the skin. And we should, in addition, endeavor to confirm our sus- 
picion by obtaining a clear history of the parents' condition at the time 
of conception. 

During the later periods of the disease, at or after the period of pu- 
berty, the diagnosis is no less important, and far more obscure. We 
must now rely upon the history of the case, upon the condition of other 
children of the same family, upon the detection of traces of the earlier 
symptoms, upon the presence of the peculiar alteration of teeth de- 
scribed by Hutchinson, of interstitial keratitis, of nodes, or of a sym- 
metrical affection of some of the cranial nerves. 

In deciding between the inherited or acquired nature of any case, 
the points which will aid us are the existence of primary disease of 
the mother at the time of delivery (which is rare, and can rarely be 
discovered even if it have been present) ; the existence of secondary 
contagious symptoms on either the mother or the nurse who suckled 
the infant; the presence of notched incisor teeth or of interstitial kera- 
titis, which are peculiar to the inherited form; and the symmetrical 
distribution of all the secondary and tertiary manifestations, which is 
asserted by Hutchinson to be also an attribute of inherited as distin- 
guished from acquired syphilis. 

Prognosis. — The most unfavorable conditions in inherited syphilis 
are, the infection of both parents ; the appearance of the disease soon 
after birth, especially in the form of pemphigus; and the occurrence of 
rapid and extreme emaciation. On the other hand, if the father alone 
has secondary symptoms, and those of a mild character; if the disease 



876 CONGENITAL SYPHILIS. 

do not make its appearance till the third or fourth week; if the general 
nutrition is not greatly impaired, and if proper treatment can be im- 
mediately instituted, the prognosis is favorable, at least as regards 
preservatio.n of life. 

Treatment. — If the previous children of a mother have proved syph- 
ilitic, it is well to subject her to a mild mercurial course during her 
pregnancy. 

In the treatment of the infant, every care must be paid to supporting- 
its strength by the most nutritious diet, if it is unable to suckle the 
mother. It is, however, improper to employ a wet-nurse, on account 
of the danger of her being infected by the child. 

In regard to medicinal treatment, the use of mercury is universally 
recommended during the presence of marked symptoms. The mercu- 
rial may be given either in the form of hydrarg. cum creta; calomel; 
or bichloride of mercury, in solution in some aromatic water, or in sjy. 
sarsse. comp. ; or, finally, it may be introduced into the system in the 
form of mercurial ointment by inunction. The most convenient mode 
of introducing it in the latter form is by smearing a flannel roller with 
mercurial ointment, and binding it around the child, whose movements 
cause its speedy absorption. 

The dose of the mercurial should be small, and it is to be continued 
steadily, though with caution so as to avoid producing salivation, until 
a decided improvement in the symptoms manifests itself. During its ad- 
ministration it will frequently have to be temporarily discontinued, on 
account of gastro-intestinal irritation. 

So soon as the mercury is stopped, we should order the iodide of po- 
tassium or iodide of iron, either one or both together being employed, 
according to the toleration of the stomach. 

We should also recommend the use of cod-liver oil, and some prepa- 
ration of cinchona, from an early period in the case; and even when 
the child suckles, a certain amount of Liebig's cold extract of meat, or 
of raw beef scraped finely and given as directed at page 415, should be 
administered. 

The best local application to the sores is black-wash, though the con- 
djdomata usually require to be touched occasionally with solid nitrate 
of silver. 



CLASS VIL 

DISEASES OF THE SKIN. 

INTRODUCTORY REMARKS. 

It will be observed tbat, in regard to some of these affections, we 
have altered the arrangement which was adopted in the earlier editions 
of this book, while retainino' the same o;eneral divisions of skin diseases: 
rashes, papules, vesicular, pustular, and squamous affections. For al- 
though none of the new classifications recently devised, some of them 
based upon the anatomical element of the skin affected, others upon 
the nature of the pathological process present, and others still u23on 
the clinical relations of the various diseases, appear to us completely 
satisfactory; still the more rigid study of skin diseases has rendered 
necessary the removal of a number of eruptions from the classes where 
they were formerly placed. We follow then the example of Wilson, 
who retains the original classification of Willan, modified and expanded, 
however, so as to harmonize with the results of more recent observa- 
tions. 

The class which will be found to have been most changed is that of 
vesicular diseases, of which eczema, a disease formerly defined to be 
characterized by the presence of vesicles, was the type. It was long 
ago evident, however, that this was not a strictly correct definition, 
since in many cases of eczema, other elements of eruption besides the 
vesicles were present. And, accordingly, the term eczema is no longer 
restricted to a purely vesicular eruption, but is erected into a generic 
title for all affections which are characterized by redness, itching, infil- 
tration of the skin, exudation on its surface, and the formation of crusts, 
whether the elementary lesion be an erythematous rash, a papule, a 
vesicle, or a pustule. In accordance with this, as will be seen more in 
detail under the head of eczematous affections, this class includes many 
cases of some affections, as impetigo, which were formerly classed 
among the pustules, and of others which were included among squa- 
mous diseases. 

It would be worse than useless in a work like the present, which is 
necessarily restricted within certain limits as to size, to attempt a full 
description of all the diseases of the skin to which children are subject. 
Such a course would compel us to devote to more important matters 
than the affections of the skin, a much smaller proportion of space 
than they require and deserve. We shall therefore select only those 



878 ERYTHEMA. 

cutaneous diseases occurring in early life, which are most important 
either from their frequency, or because they present in children some 
particular aspects or peculiarities, which make it necessary that they 
should be studied separately from the same maladies in adults. More- 
over, we shall treat of each one as it comes before us with greater or 
less copiousness of detail, according to its respective consequence to 
the medical practitioner, eschewing carefully any useless detail in re- 
gard to the more unimportant kinds, but endeavoring anxiously to de- 
scribe with accuracy the history, diagnosis, and treatment, of such as 
demand a greater degree of consideration. 



CHAPTER I. 

EASHES. 

AETICLE I. 

ERYTHEMA. 

Definition; Frequency; Forms.- — Erythema is a non-contagious ex- 
anthem, characterized by a slight and superficial redness of the skin, 
appearing in patches of irregular form and uncertain extent. It may 
or may not be preceded by or attended with signs of constitutional dis- 
order. It is quite a, frequent affection in some of its forms. 

We shall describe three /o?'ms of the disease, restricting ourselves, as 
w^e have already said that we should, to those which seem particularly 
important in infancy and childhood. These forms are Erythema Fugax, 
Erythema Intertrigo, and Erythema Nodosum, 

Erythema Fugax. — This form of erj^thema occurs chiefly in the 
course of various acute internal inflammations, and especially those 
which occur during dentition. It may occur during high febrile reac- 
tion brought on by any cause, especially in children having an active 
cutaneous circulation. We have observed it several times in the local 
inflammations accompanied with great disturbance of the circulation, 
and particularly in cases of severe catarrh occurring during dentition, 
and in attacks of severe simple angina. In these cases it appeared in 
the form of a bright red rash, resembling very much a mild scarlatinous 
eruption. It was seated upon the upper part of the front of the thorax, 
and upon the outer surfaces of the arms. The red flush disappeared 
readily under pressure, and flashed back the moment the pressure was 
removed. There was no swelling whatever attending it, and the color 
was never so bright as that of a severe scarlatina, nor so deep as that 
of erysipelas or roseola. It lasted only a few hours or half a day, and 
then disappeared without desquamation. 



ERYTHEMA INTERTRIGO. 879 

The chief point of interest in regard to this form of erythema, as it 
has come under our notice, has been the diagnosis between it and scarlet 
fever. This is to be made out only by recollecting that it has made its 
appearance in the course of another disease, while the child is already 
suffering under some kind of sickness, which is not generally the case 
with scarlatina; by the less scarlet tint of the eruption, its more super- 
ficial character, and more limited extent; and lastly, by its short dura- 
tion. 

Erythema Intertrigo. — This form of erythema was for a long time, 
and is still by some, known by the single name of intertrigo. It occurs 
on the portions of the body exposed to friction by the contact of oppo- 
site surfaces, and to irritation from the passage over, or retention upon 
them, of the urinary secretion or the fecal discharges. The most com- 
mon seats of it are, therefore, in the folds of the skin about the neck, 
in the axillae, the groins, about the anus, in the cleft of the nates, and 
on the inside of the thighs. 

As it appears in the creases of the skin about the neck, or in the axillse, 
it may be a mere red blush lasting a few days, and then disappearing; 
or, after presenting this appearance for a short time, the inflammation 
may become much more intense, and occasion an excoriated condition 
of the surfaces attended with the discharge of a serous or a sero-puru- 
leut fluid ; or, lastly, the inflammation may run into veritable ulceration, 
giving rise to extensive and very painful ulcers occupying the depth of 
the crease, presenting abrupt and jagged edges, and discharging very 
considerable quantities of pus. In these latter forms of the eruption 
it must be regarded as a true eczema, and, indeed, this form of erythema 
has been by some authorities transferred to the group of eczematous 
affections, under the name of eczema erythematosum. In one child, 
two months of age, of delicate constitution, and imperfectly supplied 
with food, we saw the last-described form of the disease occupying at 
the same time the groins, the axillse, and the folds of the neck. The 
attack lasted two weeks, and very nearly proved fatal from the violent 
suffering it caused. In another child; not quite a year old, who was 
teething, it presented these characters in the neck and axillae, while in 
the groins it was much less severe, the latter parts being merely exco- 
riated. 

Infants attacked with severe diarrhoea, with dysentery, or entero- 
colitis, and especially with that form of entero-colitis which so gener- 
ally accompanies thrush, are very apt to have an erythema of the nates^ 
genital parts, and the internal surfaces of the thighs. So common, in- 
deed, is this occurrence that M. Yalleix regards erythema of these parts 
as an almost constant accompaniment and even precursor of thrush. 
For our own part we have very often met with it in cases of diarrhoea 
in infants, even in those of very moderate severity, but we have never 
seen it precede the appearance of the intestinal disorder. 

This form of erythema begins as a simple redness of the skin about 
the anus, between the buttocks, about the genital parts, and over the 
inside of the upper parts of the thighs. In a mild case of diarrhoea, 



880 ERYTHEMA. 

and in a child properly cleansed after each evacuation by stool or urine, 
it will go no further than this : but in a severe attack of inflammatory 
diarrhoea, attended with frequent acid stools, and in a case in which 
proper cleanliness is not attended to, the long-continued contact of the 
discharges and soiled napkins will often cause the erythema to assume 
very distressing features. The redness extends in such instances along 
the legs to the feet; small papules, more or less numerous, make their 
appearance upon the inflamed skin; these are converted into pustules 
and then into ulcerations, and if the case goes on unchecked, the ulcer- 
ations become larger, run together, and present raw, deep red, and bleed- 
ing surfaces, sometimes of considerable size. Yery often the ulcerations 
present a grayish plastic exudation upon their surfaces. When these 
conditions present themselves, the case has passed into an exudative 
form^ and is properly to be regarded as an eczema pajDulosum or pustu- 
losum. After cicatrization there remain, at the points where the ulcer- 
ations had existed, reddish and copper-colored spots, which do not dis- 
appear for a considerable length of time. This form of erythema rarely 
ceases entirely until the diarrhoea which has occasioned it has itself 
been cured. 

EiiYTHEMA Nodosum generally occurs in feeble and delicate children. 
We have never met with it under five years of age. It may develop 
itself upon different parts of the body, but occurs in by far the greater 
part of the cases on the fore part of the legs, or over the anterior edge 
of the tibia. We have only twice seen it elsewhere, and then it was 
situated upon the outer surfaces of the arms and forearms. It is pre- 
ceded usually for several days by general indisposition, by lassitude, 
thirst, loss of apj)etite, and some feverish ness. It appears in the form 
of red spots of an oval shape, somewhat elevated in the centre, and 
which increase gradually in size. After a short time these patches be- 
come decidedly elevated above the surrounding surface, and in passing 
the hand over them they give the sensation of nodosities. They in- 
crease gradually in size, so as to measure from a few lines to an inch 
or an inch and a half long, by half an inch or an inch broad, when 
they present the appearance of reddish tumors, somewhat painful to 
the touch, and having an obscure feeling of fluctuation, as though about 
to suppurate. This, however, they never do, but after a short time 
they diminish in size, their red color changes into a bluish or livid tint, 
thej^ soften, and finally disappear entirely in about twelve or fifteen days. 
We have met with five well-marked cases of this disease. Three oc- 
curred in girls between six and twelve years of age, and two in boys 
of the same age. They all appeared to depend on derangement of the 
digestive function, attended with a somewhat impoverished state of the 
blood, and general debility. 

Diagnosis. — The only disorders with which erythema could be con- 
founded are erysipelas, roseola, or scarlatina, and this could happen 
only in regard to the erj'thema fugax. From erysipelas it may be dis- 
tinguished by the superficial character of the eruption, the absence of 
swelling and of smarting and burning pain, and by the slighter severity 



PROGNOSIS — TREATMENT. 881 

nnd much shorter duration of the symptoms in erythema. Another im- 
portant feature is the peculiar, abrupt, well-defined, and slightly ele- 
vated margin which marks the edge of the erysipelatous rash, and which 
does not exist with the same distinctness in erythema. Lastly, the 
singular regularity observed by erysipelas in its gradual extension 
from place to place, is altogether unlike the march of erythema, which 
shows itself suddenly-, or in a few hours, over large surfaces, and, after 
lasting some hours or a few days, quickly disappears. 

In roseola the peculiar deep rose-tint of the rash will serve to distin- 
guish between it and the lighter red tint of erythema. 

The mild character of the general symptoms, and the absence of 
throat-affection in erythema, will prevent any one w^ho is careful from 
mistaking the disease for scarlatina. 

Erythema intertrigo cannot be mistaken for any other disease, and 
if the course and peculiar local characters of erythema nodosum be 
borne in mind, it also may be easily recognized. The only thing with 
which the latter might be confounded is phlegmonous erysipelas, but if 
the mild character of the general symptoms in erythema nodosum, the 
distinctly circumscribed form of the tumors, and the fact that the dis- 
ease never terminates by suppuration, are recollected, there need be no 
difiSculty in making the diagnosis. 

Prognosis. — Erj-thema is a very mild disorder in a large majority of 
the cases. The only conditions under which it proves serious are when 
the intertrigo attacks children laboring under chronic entero-colitis, or 
those affected with severe thrush connected with gastro-intestinal in- 
flammation, when it cannot fail to increase the sufferings and danger 
of the patient; or, when it implicates, as we have seen it do in two in- 
stances, extensive portions of the cutaneous surface, involving the folds 
of the neck, armpits, groins, and genital organs, and this, too, without 
any other signs of disorder of the digestive apparatus than those show- 
ing functional derangement. In one of these cases the extent and 
depth of the ulcerations were so great, and the resulting suffering and 
constitutional distress so severe, as to have very nearly destroyed the 
life of the infant, who was but two months old at the time of the attack. 

Erythema nodosum would almost certainly excite some uneasiness 
in the mind of a practitioner unacquainted with its real nature and 
probable course, and not only so, but it would prove tedious and diffi- 
cult of cure, unless treated in the proper way. When managed cor- 
rectly, however, it almost always gets well without any difficulty. 

Treatment. — Erythema fugax requires no special treatment. The 
disorder which has occasioned it is the point to which our attention 
must be turned, and not the eruption, which is a mere consequence. 

Ordinary, mild cases of intertrigo require no other measures than 
attention to strict cleanliness. The irritated parts must be carefully 
washed two or three times a day, and if the nates, genital parts, and 
thighs are concerned, the washing must be repeated after each evacua- 
tion of urine or stool. After this the parts should be dusted with &ie 

56 



882 ERYTHEMA. 

starch, with the powder of chalk or lycopodiura, or with calomel, 
which, in our hands, has answered best of all, or else be well anointed 
with some mild ointment, the best of which is, in our opinion, G-oulard's 
cerate. The washing ought to be performed with a fine soft sponge 
and warm water. The sponge is far better than the cloth generally 
employed, because, with the former, the cleansing can be effected by 
pressure, w^hilst with the latter it is necessary to use a kind of wiping 
or rubbing process, which cannot fail to irritate the inflamed and tender 
surfaces. 

When the surfaces have become excoriated or ulcerated, attention to 
cleanliness is as important as ever. The application of the drying 
powders generally employed by the public becomes, under these circum- 
stances, insufficient, and often rather injurious, except, indeed, in cases 
in which the excoriation is very slight; here the lycopodium powder, 
or very fine starch or magnesia will sometimes answer a good purpose. 
When the excoriation is severe, and when ulceration is present, we 
have never obtained any good effects from powdering ; on the contrary, 
it has often proved injurious, and is at least troublesome and annoying 
from the incrusting of the powder about the ulcer. We prefer, there- 
fore, very greatly, when ulceration is present, to dress the part with 
simple cerate, Goulard's cerate, Turner's cerate, or with ointment of 
oxide of zinc. The ointment should be applied on a fine rag greased 
on one side, the rag being doubled and interposed in such a way be- 
tween the opposite surfaces of inflammation as to be accurately applied 
to the whole extent of the disease, and thus prevent all friction or even 
contact of the opposite sides. These compresses ought to be changed 
three or four times a day, and all the discharges gently but carefully 
washed ofl" hj pressure with the sponge between each change of dressing. 

Whilst this topical treatment is being carried out, constant attention 
must be paid to the state of the digestive function. It is scarcely 
necessary to apply this remark to cases occurring in the course of 
thrush or entero-colitis ; but there is another class of cases that we 
have met with, in which, though the intertrigo is severe and obstinate, 
lasting as much as two, three, or four weeks, the signs of gastrointes- 
tinal disorder are so slight as to pass unnoticed unless carefully inquired 
into. Thus they may consist merely in the fact that the child has a 
few more stools per day than usual, or that the stools are more liquid 
than they should be, or that they exhibit marks of derangement of the 
digestive process by the appearance in them of imperfectly digested 
curd of milk, or by their green color and sour smell. Whatever be the 
character of the derangement of this function, as shown by the general 
appearance of the child, its appetite, degree of thirsty or the appear- 
ances presented by the stools, we should always endeavor to rectify the 
disorder, and if the attempt prove successful, we shall often see the in- 
tertrigo vanish at once, while before it had resisted all the means em- 
ployed for its cure. 

Erythema nodosum occurs generally, as already stated, in feeble chil- 
dren, and is usually accompanied with constipation or unhealthy stools. 



EKYSIPELAS — CAUSES. 883 

and slight febrile reaction. The proper treatment is a laxative at the 
beginning of the attack, and again in the course of the disorder, if 
necessary ; rest in bed, or on a sofa, which is very important ; and, after 
the operation of the laxative, the administration of tonics, and the use 
of a light but strengthening diet. The best tonic, as a general rule^ is 
quinia. If this is not liked, or if there be anj^thing in the case to con- 
traindicate its emjDloyment, we may substitute the compound tincture 
of bark, in the dose of fifteen or twenty drops, three times a day. If 
the child is pale and anaemic, iron is the proper remedy. It should be 
given in connection with the tincture of bark, or with small doses of 
brandy, when the appetite is poor, and the strength and spirits of the 
child much below their natural level. 

Topical remedies are not necessary as a general rule. When, how- 
ever, the local symptoms are severe, or there is much heat or pain in 
the tumors, they should be kept covered with compresses moistened 
with some kind of mucilage, or with lead-water and laudanum. 



AETICLE II. 

ERYSIPELAS. 

Definition; Forms; Frequency. — Erysipelas is a specific, acute, 
febrile, non-contagious exanthem, characterized by a deep red rash, 
attended with heat and swelling of the skin, sometimes with inflamma- 
tion of the subjacent cellular tissue, and terminating generally in reso- 
lution, but sometimes in suppuration or gangrene. The disease is very 
variable as to its extent, and has the peculiarity of spreading from 
place to place, the part first attacked recovering, whilst the neighboring 
surface is becoming affected. 

The disease, as it occurs in children over six months of age, presents 
the same characters as in adults, and requires therefore no particular 
attention in this work. In younger children, on the contrary, and es- 
pecially in the new-born infant, it is different in several particulars from 
that of older children or adults, and this we shall attempt to describe. 
The form which occurs in new-born infants, has been technically named 
erysipelas neonatorum. 

Erysipelas is a rare disease in private practice, particularly amongst 
families in easy circumstances. In lying-in and foundling hospitals, on 
the contrary, it is of frequent occurrence, and it is not uncommon in 
hospitals for children and in the children of the poor. We have our- 
selves met with but four cases of erysipelas in children under six months 
of age, whilst we have met with seven in older children. 

Causes. — The erysipelas of young children almost always starts from 
some previously existing cutaneous inflammation, the most frequent 
seats of which are the umbilicus during the process of separation of 



884 ERYSIPELAS. 

the cord, the irritated folds of the skin existing in erythema intertrigo, 
the inflammation accompanying the vaccine disease, and that which 
exists in the eczematous and impetiginous eruptions of the scalp, ears, 
and face. In a large majority of the cases observed in new-born chil- 
dren, the disease begins upon the abdomen, and generally at the um- 
bilicus. In those which occur in children at the breast, it may show 
itself at any of the points above mentioned. 

The disease occasionally follows vaccination. "We have ourselves met 
with three instances, in two of which the erysipelas broke out about 
the eighth day; and in the third on the tenth day. In none of these 
cases could there be any doubt as to the purity of the vaccine virus 
used. In two, the disease extended over the greater part of the cutane- 
ous surface, lasting three weeks, but terminating favorably in both 
cases. In the third case, it extended over the whole of the vaccinated 
arm, then attacked the upper part of the trunk, the face, and the right 
arm, and terminated fatally in the second week. 

But, though erysipelas commonly starts from, and may at first view 
seem to be produced by these different local irritations, it is impossible 
to suppose that they can be anything more than the exciting agencies 
or causes, which bring into action a disease of which the seeds al- 
ready exist in the economy. We must, therefore, in order to under- 
stand the real mode of causation of erysipelas, seek for the conditions 
that give rise to this predisposition to the malady, without which the 
above-mentioned exciting causes would rest without effect. These con- 
ditions are either a general epidemic constitution of the air, affecting 
certain districts of countrj', and acting more or less upon all classes of 
the community, but with especial force upon the destitute and miser- 
able ; or else a local epidemic constitution, such as that often occasioned 
by the unfavorable hygienic conditions of hospitals, and particularly 
of lying-in and foundling hospitals, or that not unfrequentlj^ deter- 
mined b}^ the same causes in the crowded and miserable habitations of 
tlie poorer classes of the inhabitants of large towns and cities. 

Symptoms. — Infantile erysipelas is not generally preceded by any 
constitutional symptoms. The appearance of the eruption is usually 
the first sign of the disease. So soon, however, as the eruption appears, 
or very soon after, the child is attacked with fever, marked by frequent 
pulse, heat and dryness of the skin, restlessness and insomnia, and thirst. 
In the form of the disease which occurs in very young infants and in 
hospitals, or amongst the lower classes of the population, the eruption al- 
most al vvaj'S begins upon the abdomen, and very generally at the umbili- 
cus, whence it extends to the rest of the trunk, to the genital parts, and 
sometimes to the inferior extremities. Even under the circumstances 
just mentioned, however, the eruption sometimes commences upon the 
face or upon the limbs. In children over two weeks of age, and in 
those observed in private practice, the disease may begin upon any 
part of the surface. It very often commences in the neighborhood of 
a vaccine pock, in a patch of erythema intertrigo, whether this be 
seated on the neck or about the pelvis, or it may appear first upon the 



SYMPTOMS. 885 

face, or upon one of the extremities, without any apparent exciting 
cause, and extend thence with greater or less rapidity to other parts 
of the body. 

The form of the disease which occurs in very young infants, and 
which is by far more frequent in lying-in and foundling hospitals than 
under any other circumstances, begins almost always, at least when of 
a severe type, on the abdomen. It attacks heartj^ as well as more del- 
icate children, and is generally very rapid in its progress. The ery- 
sipelatous surflxce is at first of a bright red and shining appearance, but 
soon assumes a purplish hue, and as this occurs, becomes exceedingly 
hard to the touch, and somewhat, though not very much SM^elled. As 
the case goes on, unless resolution, which is a rare event, should take 
place, or death occur at an early period, the purple color deepens into 
livid, vesications occur, the cellular tissue is destroyed, and in many 
instances extensive gangrene takes place, so that the scrotum has been 
seen to "become black and slongh away, leaving the testicles bare, and 
hanging loose by the coi-ds." {Maiinsell and Evanson.) In a case that 
occurred to one of ourselves in private practice, the disease began on 
the ninth day at the umbilicus, and involved the soft tissues of the an- 
terior wall of the thorax and abdomen. The skin sloughed in several 
places, exposing the muscles; and at one point, just below the epigas- 
trium, perforation of the abdominal wall occurred. Death occurred on the 
fifteenth day of the disease. In this form of infantile erysipelas, ex- 
amination after death almost always discloses severe and extensive per- 
itoneal inflammation, a condition which cannot fail, of course, to add 
greatly to the danger of the disease. 

But infantile erysipelas does not always exhibit these violent char- 
acters, though whenever it occurs in infants under a year old it must 
be regarded as a very dangerous affection. When it attacks children 
over two weeks or a month old, it usually starts, as has been stated, 
from the neighborhood of a vaccine pock, from the inflamed surfaces of 
intertrigo or those of eczematous or impetiginous eruptions, or it be- 
gins without evident cause, as in adults, on the face, or on some part of 
the extremities. It appears first in the shape of a bright red inflam- 
mation of the skin. After a short time the erysipelatous surface be- 
comes tense, shining, very hot, slightlj" swelled, and painful to the 
touch. Pressure causes the color to disappear, but this rapidly returns 
when the pressure is removed. Coincidently with the appearance of 
the cutaneous redness the child is seized with fever, restlessness, and 
severe thirst. From the spot first attacked the disease extends rapidly 
to the neighboring surfaces, from the neck and arms to the head and 
trunk, and from the groins or genital parts to the rest of the trunk and 
to the inferior extremities. When it begins upon the fiice, it extends 
to the scalp, and may thence travel over the whole surface, or it may 
remain limited^ as it often does in adults, to the head alone. In one 
case that we saw, in an infant three weeks old, in which it began upon 
the face, it extended gradually over the whole cutaneous surface, and 
yet the child recovered. In another, two months old, it began upon 



886 ERYSIPELAS. 

the bridge of the nose, and from thence extended over the whole head, 
but did not reach the trunk or limbs. In a tfiird case, a vaccinated arm 
was attacked with erj^sipelas on the eighth day of the vaccination. The 
disease extended down to the fingers, and upwards to the shoulder. 
From the shoulder it spread gradually over the whole trunk, and down 
the whole length of both lower extremities. As it was subsiding on the 
feet, it appeared on the arm opposite the one first attacked, and then 
attacked the corresponding side of the head, where it ceased. The 
child finally recovered after an illness of three weeks. 

As the peculiar inflammation spreads to the neighboring surfaces, 
the parts first attacked lose their red color and swelling, and undergo 
a process of desquamation. In some instances, the inflammation has 
caused suppuration of the subcutaneous cellular tissue, so that even 
when the greater part of the surface first attacked has ceased to present 
the peculiar characters of the erysipelatous inflammation, there re- 
main behind abscesses of greater or less extent. Thus, in one of the 
cases that came under our own notice, when the erysipelas had left the 
head and thorax, and was confined to the pelvis and inferior extremi- 
ties, there were two abscesses on the scalp, and one over the right pec- 
toral muscle, whilst all the skin between the abscesses had regained its 
natural appearance, with the exception of the desquamative process, 
which was going on as usual. In another, but rarer set of cases, the 
inflammation sometimes returns to the parts over which it has already 
passed. 

The swelling which accompanies this disease is usually of an oedema- 
tous nature, — the oedema being most marked in the hands and feet, and 
upon the face, whilst upon the trunk it is much less considerable. 

The general symptoms consist at first, as already stated, of those in- 
dicating a strong febrile reaction. If the case goes on favorably these 
symptoms continue until the disorder terminates. But when the dis- 
ease is severe, and especially when it ends in vesication, in extensive 
destruction of the cellular tissue, or in gangrene, the general symptoms 
are much more violent, marking thereby the gravity of the attack. 
The face and lips become pale, and the tongue and mouth dry. The 
child is in a state of constant agitation at first, and expresses its uneasi- 
ness and suff'ering by incessant moaning or crying, but, after a time, it 
becomes heavy and drowsy from exhaustion. The pulse is very frequent 
and feeble; diarrhoea and vomiting make their appearance, and the 
child dies at last in a state of profound debility ; or convulsions occur 
towards the last, and terminate the case as they so often do in the dis- 
eases of infancy and childhood. 

The duration of erysipelas in children is extremely uncertain, and 
depends very much upon its form. In that which occurs in the new- 
born child, or within one or two weeks after birth, it sometimes proves 
fatal within seven days according to Canstatt (^Handbiich der Med. 
Klinik.^ 2d ed., vol. ii, p. 264). M. Bouchut (J/ciL des Eiif. Nouv.-Nes, p. 
532) gives as an approximation to the ordinary duration of infantile 
erysipelas, between four and five weeks, and states that this is also the 



DIAGNOSIS — PROGNOSIS. 887 

result arrived at by M. Trousseau. In one of the cases alluded to by 
us, in which the disease extended over the whole cutaneous surface, 
the duration was four, while in another it was three weeks; in the one 
in which the eruption was limited to the head, the duration was a week. 
In the seven remaining cases, the disease was limited to the nose and 
eyelids, or the face and scalj), and lasted from three to ten days. 

Diagnosis. — The diagnosis is very easy. The peculiar shade of the 
red color, the presence of decided though moderate tumefaction of the 
affected part, the severity of the general symptoms, and the character- 
istic erratic mode of extension from surface to surface, all assist to ren- 
der the diagnosis very clear to those who have a proper amount of 
medical knowledge. 

Prognosis. — Erj^sipelas is always a dangerous disease in young chil- 
dren. The precise degree of danger in individual cases will depend 
chiefly on two circumstances : first, the age of the subject; and second, 
the hygienic conditions under which the disease occurs. It is exceed- 
ingly dangerous in new-born infants, so much so indeed that M. Bou- 
chut declares that they all die (loc. cit., p. 532). This is in all proba- 
bility almost strictly true of the cases which occur in infants only a few 
days old, particularly when they take place in lying-in hospitals, or 
even in private practice, during the prevalence of an epidemic of puer- 
peral fever. The disease is always very dangerous in hospitals, even 
in infants over two weeks old. Yet it would appear not to be so grave 
as represented by M. Bouchut, who thinks that very few indeed have 
been cured even at that age; for. of thirty cases in infants between one 
day and a year old observed by Billard at the Foundling's Hospital of 
Paris, sixteen, or only one more than half, proved fatal. Schwebel re- 
ports 54 deaths in 86 cases {Meissiier, Kinder krankheiten, 3d ed., vol. i, 
p. 372). 

In private practice, erysipelas as it occurs in children between two 
weeks and a few years old, is a dangerous malady, but yet is far from 
being so in the same degree as in the new-born infant, and in hospitals. 
We have already stated that we have seen four cases in young infants; 
one nine days old, in w^hom the disease proved fatal in fifteen days; one 
three weeks old, in whom the disease lasted four weeks, and travelled 
over the whole cutaneous surface; another ten weeks old, in whom 
also it travelled over the greater part of the cutaneous surface; and a 
fourth two months old, in whom it remained limited to the head. 
These last three recovered. Again, we have seen seven cases of erj^- 
sipelas of the face or head in children between seven months and twelve 
years old, and these also ended favorably. It must be recollected, how- 
ever, to account for these recoveries, that they all occurred in hearty 
children, and under the most favorable hygienic conditions met with 
in private practice. To conclude, MM. Eilliet and Barthez report nine 
cases of erysipelas of the face in children, all of whom, with three ex- 
ceptions, were over five years of age. Five of the nine cases were idio- 
pathic; in four the disease complicated other affections. All of the 
spontaneous and one of the complicated cases recovered. The two 



888 ERYSIPELAS. 

others, both of which occurred in subjects laboring under measles at- 
tended with pneumonia, proved fatal. 

Treatment. — The treatment of erysipelas in new-born infants, espe- 
cially when the subjects of the disease are the inmates of a hospital, 
and when it occurs coincidently with a puerperal fever epidemic, is, as 
may be learned from the almost certain fatality of the disorder, ex- 
ceedingly hopeless. M. Trousseau {Barrier^ Trait e Prat, des Mai. de 
VEnfance, t. ii, p. 560) has made trial unsuccessfully of emollients in 
every form, of fomentations, lotions, baths, and of ointments contain- 
ing sulphate of iron. " I have tried," he says, " surrounding the whole 
body and limbs with blisters in the form of strips; the erysipelas has 
passed over the obstacle. I have applied without success blisters upon 
the surfaces already invaded by the inflammation. I have obtained no 
advantage from mercurial ointment or from baths containing corrosive 
sublimate." He even tried the application of the actual cautery in 
points where the disease was beginning, but without effect. So, too, 
with methodical compi-ession. 

Underwood says that "upon the complaint being first noticed in the 
British Lj^ing-in Hospital, various means were made use of without 
success; the progress of the inflammation has seemed, indeed, to be 
checked for awhile by saturnine fomentations and poultices, applied 
on the very first appearance of the inflammation ; but it soon spread, 
and a gangrene presently came on ; or where matter has been formed, 
the tender infant has sunk under the discharge." He adds that he 
then proposed bark, to which, sometimes, a little confectio aromatica 
was added, and that, from that period, several cases recovered. After 
this, linen compresses, wrung out of camphorated spirit, were applied 
in the place of the saturnine solution, and proved successful in several 
instances in checking the inflammation. " Nevertheless, the greater 
number of infants attacked with this disorder sink under its violence, 
and many of them in a very few days.'' {Treat, on the Dis. of Children^ 
Am. ed., by Dr. Bell, from the 9th Eng. ed., p. 103.) In a note to the 
above. Dr. M. Hall states that fomentations of extract of poppies dif- 
fused in warm water, and poultices consisting of the same fluid and 
crumbs of bread, proved beneficial in many instances. Dewees recom- 
mends the application of a blister, when the erysipelas is so situated as 
to allow the whole surface of inflammation and a portion of the neigh- 
boring healthy surface to be covered by the plaster. When this cannot 
be done, he prefers the use of the strong mercurial ointment, which 
must be applied over the whole of the eruption, and partly upon the 
healthy skin, and renewed as often as the part becomes dry. 

It is very difficult amidst the variety of advice given bj different 
writers, and especially when we reflect upon the great mortality of the 
disease under every kind of treatment, to determine which to select. 
For our own part, we should prefer the use of cooling emollient appli- 
cations during the first part of the attack, whilst the skin is of a bright 
red color, hot, and shining. When the circulation becomes languid, 
and the color of the eruption is disposed to deepen from red to purple, 



TREATMENT. 889 

we should suspend tbe use of the emollient applications, and employ in- 
stead the lotion of camphorated spirit recommended by Underwood; 
the camphorated tincture of soap, which we have known to be of c^reat 
service in the erysipelatous inflammations occurring in patients of 
broken down constitution, and which is to be applied three or four 
times a day b}' means of a soft sponge ; or lastly, we would make trial 
of Kentish's ointment, a remedy found of great service by the late Dr. 
Charles D. Meigs, in the erysipelas of children {North Amer. Med. and 
Surg. Journ., vol. vi, p. 77). This ointment he prepared by rendering 
basilicon ointment soft (not fluid) with spirit of turpentine. It is 
rubbed upon the inflamed part with the fingers, the anointing being 
" repeated often enough to keep the part always very thinly covered.'' 
The internal treatment should consist in attention to the state of the 
bowels, which are to be kept soluble by the mildest laxatives, without 
being purged, and in a resort to tonic and stimulating remedies upon 
the very first approach of symptoms indicating exhaustion. The best 
remedies of this class are proper diet, wine whey, small quantities of 
brandy, and bark in connection with minute doses of carbonate of am- 
monia. 

In addition to these, the tincture of the chloride of iron, whose re- 
markable and almost specific influence upon the course of erysipelas in 
more advanced life is so well established, should be given in large 
doses, proportioned to the tender age of the patient. Thus we may 
give two or three drops every three hours to an infant of a month old, 
as in the following formula : 

R.— Tr. Ferri Chloridi, fgss. 

Acid. Acetic Dil., f^ss. 

Liq. Ammonias Acptat., ..... f^j. 

Syr. Simp., f^ss. 

Aquse, ad f^iij. — M. 

S. — A teaspoonful every three hours. 

When the inflammation has gone on to the production of subcutane- 
ous suppuration, it becomes still more important to sustain the forces 
of the constitution, by giving the infant a healthy and abundant breast 
of milk, and by the internal use of brandy in small quantities, of bark, 
or better still, of quinia in combination with small doses of carbonate 
of ammonia. At the same time the suppurating surfaces must be well 
fomented, and dressed with warm poultices, and, when necessarj^, laid 
open by careful incisions, observing the precaution to cause as small a 
loss of blood as possible. If the case occur in a hospital, or in a child 
placed in unfavorable hygienic conditions, let the following statement 
of M. Barrier (loc. cit., t. iii, p. 562) be borne in mind : " However much 
the life of an infant be threatened by erysipelas, if we can but persuade 
a wet-nurse to take charge of it, the pure air of the country is often 
seen to replace most advantageously all other therapeutical resources." 

As the preceding remarks have been restricted to the form of the 



890 ERYSIPELAS. 

disease which occurs in infants under two weeks of age^ we have now 
to make some observations on the cases which occur in older children. 

The disease is still, even at this latter age, a very dangerous one, 
though much less so, certainly, than in the new-born child. We have 
been deterred from the use of depletion in any form by two reasons, — 
the fear of exhaustion, which is so apt to occur in the disease, and the 
apprehension lest the leech-bites or cup-marks, in the case of local de- 
pletion, might prove new foci of the erysipelatous inflammation. The 
only internal remedies necessary in the beginning, are such laxatives 
as may be required to keep the bowels soluble when they are bound, 
such as shall correct acidity or diarrhoea when either is present, and 
those which promote an open state of the skin, and a free discharge of 
the urinary secretion. For the latter purpose we know none better 
than the solution of the acetate of ammonia, and the sweet spirit of 
nitre, about twenty or thirty drops of the former, with five of the 
latter, in sweetened water, to be repeated every two or three hours. 
The tincture of the chloride of iron should also be given, in the combi- 
nation before recommended, in large doses, as three to six drops, every 
three hours, at the age of one or two years. Should the attack be at- 
tended by any symptoms of prostration, or at a later period of the dis- 
ease, when the child begins to emaciate and grow feeble, its strength 
must be carefully supported by the use of proper diet, and of stimulants 
and tonics. The only proper diet for nursing children is, of course, 
breast-milk : for those who have been weaned, the diet should consist 
of preparations of milk, light animal broths, or beef tea. The best 
stimulants are five or ten drops of brandy, five drops of aromatic spirit 
of hartshorn, or a quarter or sixth of a grain of carbonate of ammonia, 
in weak syrup of ginger, to be administered four or five times a day, or 
more frequently, when the forces of the child are greatly prostrated. 
The proper tonic is from a quarter to half a grain of extract of bark, 
or half a grain of quinia, in some suitable vehicle, every three or four 
hours. 

The best local treatment is, in our opinion, cooling or tepid emollient 
applications, as slippery elm bark, marsh-mallow, or flaxseed tea, during 
the first few days, whilst the reaction is marked, and the calorification 
of the body high. Somewhat later, when the strength begins to be re- 
duced, and the color of the eruption to deepen, we should make use 
either of mercurial ointment, which is highly recommended by some, 
or of the Kentish's ointment, or camphorated tincture of soap, to which 
attention has already been called. We would here propose the trial of 
an ointment which w^e have found not only soothing and comforting to 
the child, but also of manifest curative efficacy in the violent cutaneous 
inflammation of scarlatina. It consists of one ounce of fresh cold 
cream, rubbed up with a drachm of glycerin. It should be smeared 
over the inflamed surface several times a day, and need not interfere 
with the use of emollient applications. In scarlatina it has been most 
useful in reducing the burning heat of the eruption, and in softening 
the harsh and distended skin, and by these effects has aided greatly in 



ROSEOLA — CAUSES. 891 

moderating the severity of the general, and especially of the nervous 
symptoms. 

In children over two or three years of age, erysipelas must be treated 
on the same principles as in adults, by light but nourishing diet, and 
rest in bed, by the internal use of laxatives occasionally, of full doses 
of the tincture of chloride of iron, and of febrifuges, and by the exter- 
nal application of emollient infusions, so long as the symptoms remain 
acute and the strength unreduced. But when, after a time, the fever 
begins to subside, or the child begins to show signs of debility and a 
tendency towards the typhoid condition, we must endeavor to maintain 
the life-actions in a proper degree of energy by a more nourishing and 
abundant diet, by the prudent administration of bark or quinia, and 
even by the use of brandy and ammonia, should the strength of the 
patient be disposed to give way suddenly or rapidly. Under these cir- 
cumstances, moreover, the best local application will be either the Kent- 
ish's ointment, or the camphorated tincture of soap. 



AETICLE III. 



ROSEOLA. 



Definition; Synonyms; Frequency; Forms. — Eoseola is a non-con- 
tagious, fugacious exanthem, characterized by rose-colored patches, of 
irregular size and shape, which are unaccompanied by elevations or 
papules, and the appearance of which is preceded and accompanied by 
febrile symptoms. 

It is often called in this country scarlet rash, and under that title 
supposed to constitute a very mild form of scarlatina. It is sometimes 
called also French measles, and rubeola sine catarrho. 

Eoseola is of rather frequent occurrence amongst children, though 
more rare than either measles or scarlet fever. 

There are three forms of the disease met with in children, roseola 
sestiva, roseola autumnalis, and roseola annulata. As the two former, 
however, present no differences of any importance, we shall describe 
them under one head, whilst the latter, quite unlike the other two, re- 
quires that we should describe it apart. 

Causes. — Eoseola maj- occur at all ages of infancy and childhood, and 
at any se(2son, but is most common in summer and autumn. It has been 
known to prevail as an epidemic, but has never been thought contagious. 
It may attack the same individual on several different occasions, one 
attack not preserving from repetitions. The variolous eruptions are 
sometimes preceded by roseola, and in some children it makes its ap- 
pearance on the ninth o^ tenth day of the vaccine disease. Of the va- 
rious causes that we have known to produce it, the most frequent is 



892 ROSEOLA. 

certainly derangement of the digestive function during the first denti- 
tion. It is said also to be occasioned by sudden changes of tempera- 
ture, by violent exercise, and by the use of cold drinks while the body 
is heated and moist with perspiration ; causes which strongly indicate 
that the nervous system is closely connected with its production. 

Symptoms. — Young children who have been suffering for a few days 
with disorder of the digestive function, often exhibit a slight roseolous 
eruption, lasting twenty -four or thirty-six hours, and then disappearing. 
The eruption in this mild form of the disease appears suddenly, often 
in the course of a single night, covering the trunk or even the whole 
surface with numerous patches, nearly circular in shape, or in irregular, 
broad, and waving lines, situated close together and yet distinct, and 
of a light rose color. In another, and rather more violent form, occur- 
ring especially during dentition, the eruption appears after vomiting, 
fever, diarrhoea, and slight nervous s^'mptoms, or possibly after slight 
convulsions, with the characters above mentioned; except that the rash 
is deeper in color, greater in extent, and that it lasts generally a longer 
time — tAvo, three, or four days. Again, in a yet more marked form, the 
roseola aestiva and autumnalis, the disease is preceded by certain symp- 
toms which it is important to note. It begins with more or less chilli- 
ness, alternating with heat, with loss of strength and spirits, with head- 
ache, restlessness, sometimes mild delirium, and even, it is said, though 
we have never seen them, with slight convulsive phenomena. At the 
same time there is some febrile reaction, marked by accelerated pulse, 
heat and dryness of the skin, thirst and loss of appetite; the digestive 
function is shown to be deranged by the presence either of constipation 
or diarrhoea. After these symptoms have continued for two, three, four, 
or even six or seven days, the eruption appears first upon the face and 
neck, whence it extends in twenty-four or forty-eight hours to the rest 
of the body. The rash resembles very closely, in some cases exactly, 
that of measles. It is in the form of irregularly circular and rather 
large patches, at first of a red, but soon changing to a deep rose color, 
and separated from each other by portions of healthy skin. The erup- 
tion is sometimes accompanied by itching, and sometimes by stinging 
pain, and the febrile symptoms generally continue, though moderated 
in degree, after the appearance of the rash; while in other instances 
the fever disappears entirely from that moment. The rash lasts be- 
tween one, and two or three days, as a general rule, and fades away 
gradually until it has entirelj^ disappeared. In some cases it comes 
and goes alternately for a week after its first appearance. 

EosEOLA Annulata is a curious and interesting form of the disorder, 
from the singular and beautiful appearance of the bright rose-colored 
rings which constitute the eruption. We have seen but a few examples 
of this variety, while we have met with a large number of cases of the 
other forms. It must, however, be of very rare occurrence, since MM. 
Guersantand Blache state that they have never chanced to meet with 
it, though they have seen a large number of roseolous eruptions (^Dict. 
de Med., t. xxvii, p. 626). 



DIAGNOSIS. 893 

This variety of roseola appears in the form of rosy rings, or circles, 
whose centres retain the natural color of the skin. The favorite seats 
of the eruption are the abdomen, loins, buttocks, or thighs, or it may 
cover the greater part of the body. In one case that we saw, the 
eruption covered the face, neck, and trunk. In another it was seated 
upon the face, trunk, and upper extremities. The rings are at first not 
more than one or two lines in diameter, but they enlarge graduall}^ 
until their centres measure as much as half an inch in diameter. In 
some instances two or three rings surround one another, the skin in 
the intervals between them still retaining, however, its natural appear- 
ance. The disease is, when accompanied by symptoms of reaction, 
usually of short duration. The cases which occurred to ourselves 
lasted only three days, and were accompanied by decided febrile symp- 
toms, together with signs of digestive derangement. It sometimes as- 
sumes a chronic form, the eruption fading in color in the morning, and 
increasing again and causing heat of skin, in the evening. 

Diagnosis. — Eoseola sestiva might be readily mistaken by a careless 
observer for measles or scarlatina, and especially for the former. We 
have no doubt whatever that cases of roseola are often regarded, under 
the title of scarlet rash, as examples of a veiy mild form of scarlatina, 
a misapprehension which will explain some at least of the supposed in- 
stances of second attacks of scarlet fever in the same individual. This 
is a mistake, however, that ought not to occur, and need not, if the fol- 
lowing characters of the two diseases are properly understood. The 
rash in scarlatina is, in the first place, of a much brighter tint, and it 
is more persistent and more uniformly spread over the surface than in 
roseola. When we come to analyze the characters of the two eruptions, 
there are other distinctions between them which assist greatly in mak- 
ing the diagnosis. In scarlatina, the eruption is composed of very large 
patches, or it is absolutely uniform, and evenly distributed over large 
surfaces, as over the whole trunk, or over the flexor or extensor as- 
pects of the limbs. It is seen to be composed, too, when minutely ex- 
amined, of an aggregation of very minute red points, which are dotted 
so closely together, as to present the appearance of a general scarlet 
blush. In roseola, on the contrary, the rash is composed of irregularly 
circular, crescentic, or waving patches, with portions of skin between 
of a natural or nearly natural color. The patches, moreover, are of a 
different tint from that of scarlatina, being of a deep rose, instead of a 
bright red or scarlet color, and they cannot, upon close examination, 
be resolved into the minute dotted points which make up the scarlat- 
inous eruption. When we add to these circumstances the facts, that in 
roseola there is no faucial inflammation, that the pulse has not the 
great frequency almost invariabl}" present even in very slight cases of 
scarlet fever, that all the general symptoms are much less strongly- 
marked, that no desquamation takes place in roseola, and that the dura- 
tion of the attack is much shorter, we think we have points of differ- 
ence between the two, quite numerous and marked enough, to render 
the differential diagnosis easy to a careful observer. 



894 URTICARIA. 

r 

It has always seemed to us impossible to distinguish with certainty 
between roseola and measles by the eruption alone, and we find that 
MM. Eilliet and Barthez are also of this opinion (^Mal. des Enfants, t. i, 
p. 732). We are told by writers that in roseola the patches composing 
the eruption are more distinct, larger, paler, and more irregular in shape 
than in measles, and that they are separated by intervals of healthy 
skin ; but we are quite satisfied that, in some cases w^itnessed by our- 
selves, these differences were not sufficient to distinguish them. The 
diagnosis is to be made by attention to the following points : by the ab- 
sence of catarrhal symptoms in roseola, by the slighter severity of all 
the general symptoms, and by the much shorter duration and greater 
irregularity of the initial phenomena, which latter seldom last in roseola 
more than one or two days, and consist of symptoms of gastro-intes- 
tinal derangement, whilst in measles they last three and almost al- 
ways four full days, and consist of very strongly marked catarrhal or 
respiratory symptoms, with very slight signs of gastro-intestinal de- 
rangement. 

Eoseola annulata is so peculiar and characteristic in all its appear- 
ances as to prevent its being mistaken for any other disease that we 
are acquainted with. 

Prognosis. — Eoseola is probably never dangerous to life. If it ever 
seems to be so, it must be in consequence of its occurring in connection 
with severe internal disease. 

Treatment. — The onl}^ treatment necessary in roseola is attention 
to diet; the correction by that means, or, if necessary, by a mild lax- 
ative, by some antacid preparation, or by a mercurial dose, of the gas- 
tric or intestinal disorder; rest in bed, or seclusion in a chamber with a 
properly regulated temperature; and the use of mild diaphoretics and 
of cooling demulcent drinks. 



AETICLE lY. 

URTICARIA. 

Definition; Synonyms; Frequency; Forms. — Urticaria is a non- 
contagious exanthem, characterized by hard elevations upon the skin, 
of uncertain size and shape^ and of a reddish or whitish color, or, more 
frequently, partly red and partly white; the eruption is generally of 
short duration, is almost always accompanied with intense heat, and 
violent itching and burning, and is preceded by more or less marked 
signs of gastro-intestinal disorder. 

Its most common title is that of nettle-rash. The mild, discrete form 
of the disease is generally called hives in the nursery. It is sometimes 
described under the name of essera. It is of very frequent occurrence 



CAUSES — SYMPTOMS. 895 

amongst children in a mild shape. We have seldom seen in early life 
the abundant and severe eruption covering the greater part of the sur- 
face, which is met with in adults. 

The most common form of urticaria in adults is well known to be the 
urticaria febrilis, which is an acute disease of short duration. Two 
other forms of the disease, the urticaria evanida and tuberosa, are occa- 
sionally met with in adults, though they are both rare. In children, 
by far the most frequent form of the disease that we have seen is one 
in which there is scarcely any fever whatever, and in which the erup- 
tion is moderate; the urticaria febrilis is, however, not at all uncommon 
in early life, while, on the other hand, we have never met with an in- 
stance either of urticaria evanida or tuberosa at the age referred to. 

Causes. — Children possessing a fine and delicate skin, especially 
when they are at the same time endowed with a highly nervous tem- 
perament, are particularly predisposed to attacks of urticaria. • The 
only other causes that we are acquainted with are the functional dis- 
orders of the digestive apparatus which occur in the spring and summer 
seasons, the influence of dentition, derangement of the gastric functions 
from the use of improper food, and lastly, the ingestion of certain ar- 
ticles of diet, which have been proven by long experience to be apt to 
occasion attacks of the disease. Of the articles last referred to, those 
which most frequently produce this effect are crabs, the eggs of certain 
kinds of fish, certain crayfish, and some kinds of smoked, dried, or 
salted fish. 

Some children are exceedingly liable to the appearance upon differ- 
ent parts of the body of a few patches of urticaria. Yery slight dis- 
turbances of the gastric functions, a very warm day, or excessive 
clothing, will occasion in such subjects an attack of the disorder; whilst 
in many others again, the disease is never seen under any circum- 
stances, or only at rare and long intervals. 

Sy^jptoms. — The form of the disorder most commonly met with in 
children, in which there is neither fever nor other marked signs of dis- 
order of the general healthy is the disease generally described under 
the title of lichen urticatus, but which ought, it seems to us, to be con- 
sidered as one of the varieties of urticaria. This eruption consists of 
large inflamed papules, which are irregular in shape, being either 
rounded or oblong, projecting most in the centre, and which appear 
suddenly, without any or with only slight prodromic symptoms. The 
papules are of a bright red color, excepting in their projecting central 
portions, where they are whitish or of a very pale red tint. The erup- 
tion is accompanied with a smarting and burning pain, and with the 
most violent and annoying itching, which the child endeavors to allay 
by frequent and often rude scratching. It is very fugacious in its 
character, appearing suddenly, lasting for a few hours or several days, 
and then disappearing entirelj^ or recurring again after a short time 
in the same or in new places. It terminates finally, after from a few 
days to several weeks, b}^ resolution or by a slight furfuraceous des- 
quamation. The most common seats of the eruption in children are 



896 URTICARIA. 

the fiice, about the buttocks, or upon the thighs, or upper part of the 
arms. 

This is the form of the disease we have met with in infants, and in 
children under two and three years of age. It is, as already stated, of 
very slight consequence, being merely annoying and never dangerous. 
In 3'oung infants it occasions sometimes much crying and irritability, 
which can be explained only by the discovery of the eruption. 

The urticaria febriUs is usually, but not always, preceded for a few 
hours or two or three days, by feverishness, and by more or less marked 
signs of gastric disorder, such as nausea, chilliness, headache, and lan- 
guor. In other instances the fever and the rash occur at the same 
time. The eruption begins with a sense of itching, and with heat and 
burning of the skin, and soon after there appear on the shoulders, loins, 
inside of the arms, and about the thighs and knees, reddish and solid 
elevations, irregular in outline, but generally roundish or oblong. The 
latter shape is the one the elevations most frequently assume, and it is 
from the resemblance which they bear in this form to the marks left 
by the stripes from a rod or whip-lash, that they are often called weals. 
The elevations project a good deal above the surrounding surface, form- 
ing knots or ridges; their size is variable; they have hardened edges; 
they are reddish in color, except over the central and most projecting 
part, which is generally, and always when the swelling is considerable, 
whitish in its tint; and they are surrounded by a narrow areola of a 
bright red or scarlet color. The amount of the eruption is very uncer- 
tain, the elevations being sometimes separated by considerable intervals 
of healthy skin, while in severe cases they are extremely numerous, 
and from their confluent character in such attacks, give to the part 
upon which they are seated, a nearly uniform red color, and occasion 
at the same time a very decided puffing and swelling of the skin. 

The eruption, when at all considerable in degree, is attended with 
violent itching and burning. The former is often so severe and trouble- 
some as to occasion the most distressing irritation to the patient, pre- 
cluding all comfort or quiet. It is increased hj heat, and especially by 
that of the bed. The patches of eruption which appear first do not 
continue throughout the disease, but, after lasting from a few minutes 
to a few hours, fade away, and are replaced by new and successive 
crops. During the attack, the patient is usually more or less feverish, 
and he suffers from languor, loss of appetite, furred tongue, and the 
usual signs of gastric derangement. The symptoms subside gradually, 
so that, after a period varying from two or three days to a week, the 
disorder has entirely disa^^peared, leaving behind no traces, except, in a 
few instances, a slight desquamation. 

When this form of urticaria follows the ingestion of certain articles 
of food, the eruption usually appears within a very few hours after the 
meal, being preceded and accompanied by nausea or vomiting, pain and 
distress in the epigastric region, giddiness, headache, and feverishness. 

Diagnosis. — There can be no difficulty in recognizing a case of urti- 
caria. The peculiar characters of the eruption, and especially the size, 



PROGNOSIS — TREATMENT. 897 

shape, and color of the solid elevations of which the patches consist, 
the violent itching and burning which accompany it, and its fugacious 
character, render it unlike any other cutaneous disease, and ought to 
2)revent any mistake as to its nature. 

Prognosis. — Urticaria is probably never dangerous in children. If 
it be accompanied by symptoms of a threatening or alarming character, 
these are dependent rather upon the gastric disorder, which is the 
cause of the urticaria, than upon the latter aifection itself We have 
never known it to be more than troublesome and annoying. 

Treatment. — There are but two really important indications for the 
treatment of this disease : to attend to the state of the digestive func- 
tions, and to allay, by proper means, the distressing irritation occasioned 
by the itching and burning of the eruption. 

In the mild form of urticaria, called in the nursery, " hives," and in 
scientific language, lichen urticatus, the only treatment necessary is 
careful regulation of the diet, and the use of means proper to correct 
any evident derangement of the digestive functions. The food should 
be light and digestible, but at the same time nourishing. Milk, bread, 
light meats, and the plainest vegetables, form the proper diet for chil- 
dren over three years of age. Under that age, milk preparations, 
bread, and in those over a year old, light broths, ought to constitute 
the diet. In a large majority of such cases, no drug whatever ought to 
be given. The only ones likely ever to be required are occasional mild 
laxatives or gentle mercurials, when constipation is present, and some 
of the antacids, as very small quantities of magnesia or carbonate of 
soda, or lime-water and milk, when the stomach is acid. To allay the 
itching and consequent restlessness of the child, the patches of erup- 
tion should be well and frequently dusted with toasted rye or wheat 
flour, which are often very successful. Washing the eruption with salt 
and water, when the cuticle is not broken, is sometimes very soothing, 
and, when the patches are of small extent, this may be done without 
any impropriety. Dr. Watson speaks well of a lotion ("first reconi- 
mended by Wilkinson"), composed of a drachm of carbonate of am- 
monia, a drachm of acetate of lead, and eight ounces of rose-water. 

In the urticaria febrilis the treatment must depend upon the cause of 
the attack. When it follows upon the eating of some unwholesome 
food, we must rid the stomach of the offending substance by an emetic, 
unless nature has already caused its rejection by spontaneous vomiting. 
When this end has been gained, it will be proper to give some kind of 
cathartic medicine, and the best is castor oil, as the mildest and most 
certain, in order to insure the discharge of the whole of the aliment 
which has been causing the mischief; or small doses of blue pill ; or 
hydrargyrum cum creta, with rhubarb, where there are present any 
signs of hepatic derangement. After this the only treatment necessary 
will be the use of cooling and demulcent drinks, containing perhaps a 
little sweet spirit of nitre; rest in bed, or at least seclusion in the house, 
for a few day^; and careful regulation of the diet. The latter ought to 
be very light during the continuance of the eruption, consisting merely 

67 



ECZEMATOUS AFFECTIONS. 

of milk and bread, or of some kind of gruel or plain broth ; after the 
cessation of the disease, it should be augmented only with due care and 
quite gradually. To allay the itching and burning of the eruption, and 
the general distress of the child, the best remedy is a warm bath care- 
fully administered. This may be repeated in six or eight hours if neces- 
sary, and between whiles the surface should be dusted with rye or 
wheat flour, as above recommended. 



CHAP TEE II. 

VESICLES. 

AETICLE I. 

ECZEMATOUS AFFECTIONS. 

As already stated in our introductory remarks on skin diseases, the 
idea of eczema is no longer restricted to a disease characterized by the 
formation of vesicles, but embraces all the numerous affections which 
present redness of the skin, frequently punctated; itching, infiltration, 
and exudation on the surface, with the formation of crusts. So far, in- 
deed, from vesicles being characteristic of it, it may be said, and espe- 
cially in regard to eczema in children, that its rarest form is that which 
is attended solely with their formation. The elementary lesions which 
may be present at the beginning of the attack, are either erythema, 
papules, vesicles, or pustules, and the disease is divided accordingly into 
eczema erythematosum ; eczema papulosum, which embraces eczema 
lichenoides, and eczema prurigosum ; eczema vesiculosum, the typical 
eczema of Willan, one of the rarest of all its varieties; eczema pustu- 
losum, or impetiginoides, which includes impetigo; and eczema squam- 
osum, which is usually of the chronic form, and resembles, in many 
cases, psoriasis. It is indeed called psoriasis by Dr. Wilson, who gives 
the name " alphas" to that scaly disease, which is still, by most author- 
ities, and especially by Hebra, designated as psoriasis. 

]t not unfrequently happens, also, that the various elementary lesions 
enumerated above may be present at the same time on a patch of ec- 
zematous eruption, so that a case which has begun as eczema erythema- 
tosum, or vesiculosum, may present the development of papules or pus- 
tules, or thick scabs, and thus become converted into the pustular or 
squamous form. This tendency for the blending of several elementary 
lesions in the same eruption, and especially for the conversion of the 
eruption into the pustular form, is very markedly seen in cases of eczema 
of children. 



CAUSES — SYMPTOMS. 899 

Eczema is also divided according to its course, duration, and stage, 
into acute and chronic. 

Eczema shows, moreover, an especial tendency to attack certain parts 
of the surface, and presents various peculiarities in the different locali- 
ties; in children, it frequently occurs on the scalp and face, though it 
extends over the entire surface of the body far more frequently in them 
than in adults. 

The special forms of eczema which will be here described, are simple 
acute eczema; eczema of the scalp, and of the face; eczema pustulo- 
sum, or impetigo; eczema papulosum ; and chronic eczema, or eczema 
squamosum. 

Causes. — The causes of these affections are, to say the least, very 
obscure in most cases. It is probable that some peculiarities of con- 
stitution predispose to it, and particularly the lymphatic temperament, 
or the scrofulous or tubercular diathesis. Exposure to unhealthy 
hygienic conditions, as want of cleanliness, insufficient or improper food, 
and crowded or ill-ventilated habitations, also render the system more 
prone to the development of eczema. 

In those who are thus predisposed, any trifling irritation may prove 
sufficient to provoke the eruption. One of the most common and un- 
doubted of these is the influence of the process of teething, and the 
majority of cases of eczema in children occur during either the first 
or the early part of the second dentition. In like manner the applica- 
tion of irritants of any kind to the skin, or the inflammatory action 
set up by vaccination, may serve as an exciting cause. It is remark- 
able, also, what slight irregularities in diet, or alterations in the quality 
of the mother's milk, will, under such circumstances, induce an attack. 
Indeed, the use of artificial food in infancy, by disordering the diges- 
tive function, and impairing nutrition, may be regarded as a frequent 
cause of the disease. 

Symptoms. — We have already alluded to the fact, that in the eczema 
of young children, as indeed is true, to a less degree, of the disease at 
all ages, we constantly meet with the most varied forms of eruption 
in the same case; and have the opportunity of watching the develop- 
ment of papules, vesicles or pustules, until a case which has begun as 
one of erythematous eczema, presents the characters of the papular, 
vesicular, and ultimately of the pustular form. The predominance of 
one or the other of these typical forms of eczema is determined by the 
temperament and general condition of the child, and the grade of in- 
flammatory action present. 

Eczema simplex, or vesiculosum,, may occur on any part of the bodj^, 
but in children is most frequent on the face and arms. The eruption 
appears, without any precursory symptoms, as an erythematous patch, 
\vhich is red and itchy, and may present slightly raised pimples, and 
being rubbed and scratched, soon presents the formation of numerous, 
closely aggregated, exceedingly minute vesicles, containing a tratispa- 
rent limpid serum. After a short time the contained fluid becomes 
turbid and then milky, and is either absorbed, while the vesicles shrivel 



900 ECZEMATOUS AFFECTIONS. 

up and disappear by a slight desquamation, or else the fluid escapes by 
the rupture of the vesicles, and little thin scales follow, which are de- 
tached before long from the surface beneath. The eruption is attended 
with more or less itching and smarting, but does not generally give rise 
to constitutional symptoms. The vesicles are generally renewed by 
successive crops; so that, though the case may terminate in from two 
to three weeks, it is apt to continue for two or more months. 

Eczema Papulosum. — In the same way as the above form of eczema 
is characterized by the formation of vesicles, there are other cases where 
the eruption principally consists of papules, associated with erythema- 
tous patches. These papules do not remain dry and without exudation, 
as in the typical forms of lichen and strophulus, but soon present a 
slight clear or turbid serous oozing, and thiti scaly desquamation of the 
epithelium. At the same time there wnll usually be found, on other 
parts of the body, patches of more fullj^ developed eczema. The pap- 
ules in eczema infantile may either be firm, small, and conical, as in 
lichen agrius, or softer, and more broad and flat, as in some forms of 
strophulus. 

Eczema Pustulosum or Impetiginoides. — Under this head we will de- 
scribe the affection usually styled impetigo, and formerly classed among 
the pustular diseases of the skin, but which possesses peculiarities which 
have induced dermatologists to transfer it to the group of eczematous 
affections. 

It may be described as a form of eczema characterized by the pro- 
duction of psydracious sero-pustules, containing a thin purulent fluid, 
which either break and discharge, or dry up and form thin amber-col- 
ored or more thick yellowish-brown crusts. 

The eruption usually begins as a reddened patch, studded with slightly 
raised pimples. As the inflammation increases, the cuticle is often raised 
into more or less well-defined vesicles, or the surface becomes excoriated, 
and there is a discharge of turbid or whitish-yellow secretion ; the skin 
now becomes infiltrated, and numerous rather small pustules, contain- 
ing a light-colored pus, form on the red swollen \surface. 'Not unfre- 
quently there are vesicles on the same patch, surrounding its margin. 
These pustules are usually broken by scratching or by friction against 
the dressings, and their contents dry up, forming amber-colored or 
brownish crusts. Frequently, also, blood is mingled with the discharges, 
and the crusts become dark-colored, or at times positively black. 

The crusts separate in a few days, the time varying according to 
their firmness and thickness, and leave the surface reddened, but with- 
out any permanent scar. Frequently, however, the disease passes into 
a chronic form ; the eruption retreats to certain seats, as the scalp, or 
the flexures of the joints, where the skin remains somewhat infiltrated, 
while the cuticle is rough, scaly, and constantly desquamates, either in 
the form of a fine furfuraceous exfoliation, or of scales of considerable 
size. 

There are in reality but two specific varieties of this form of eczema, 
impetigo figurata, and impetigo sparsa, so named from the manner 



SYMPTOMS OF ECZEMA CAPITIS. 901 

in which the pustules forming the eruption are arranged. From the 
greater frequency and severity of the disease, however, as it appears 
upon the scalp in young children, it has become customary to describe 
it, when seated upon that part, under a different title. 

Eczema capitis is often met with in infants at the breast during the 
first dentition, and at later periods of childhood, in those who are scrofu- 
lous, or who are placed in unfavorable hygienic conditions. It may be 
confined to a small portion of the scalp, or it may cover the head, and 
extend to the face and neck; or again, it may be limited entirely to 
the latter localities, when it constitutes eczema of the face. In both 
cases, the eruption is very apt to run into the pustular form, constitu- 
ting the disease known as impetigo capitis. 

When mild in its features, it consists of an eruption of numerous 
small vesicles or sero-pustules, spread over certain portions of the scalp, 
to which it may remain limited; or it may cover the face at the same 
time, or it may attack alone the forehead, temples, and, perhaps, por- 
tions of the cheeks. It is attended, under these circumstances, with 
very slight redness and heat of the integument. The sero-pustules dis- 
charge their fluid contents and form thin crusts, which gradually fall 
off, leaving slightly reddened or excoriated surfaces, which soon disap- 
pear, or are followed by fresh crops of eruption, destined to pass through 
the same changes as the preceding ones. 

In more severe cases the disease may be confined either to the scalp 
or face, or it may, as stated above, exist upon both simultaneously. 
The eruption presents different appearances in these two situations. 

When seated on the scalp, it is often called by the English milky 
crust or milk-crust, crusta lactea, tinea lactea, and porrigo larvalis; 
and by the French, croute de lait and gourme. 

On the scalp, as already said, the eruption niay be either partial or 
general. It may consist at first of disseminated minute vesicles, which 
break, and form thin, lamellated crusts, of a yellowish or brownish 
color; or of pustules, yellowish-white in color, and of small size, seated 
on an inflamed base. The surface affected is at first small, but the 
eruption gradually extends to surrounding parts. It is attended with 
great heat and itching; and, as the disease advances, the scalp be- 
comes very much inflamed, red, tense, swollen, and painful. The erup- 
tion is now more completely pustular, and as the pustules open or are 
torn by the uncontrollable scratching, they discharge an abundant thin 
sero-pus, or even a thick and viscid fluid, which glues the hairs to- 
gether, and hardens into uneven brownish-yellow crusts. If the scalp 
is not kept clean by constant washing or by emollient applications, the 
crusts increase rapidly in thickness by successive discharges of fluid 
from the pustular surface beneath, until at length the whole of the dis- 
eased part is covered with thick, heavy, rough, and adherent crusts, of 
a brownish or yellowish-white color, or at times of a positive black 
from the admixture of blood which oozes from the inflamed surfiice, 
torn by the nails of the little sufferer. 

When neglected, the crusts become more and more thick, and from 



902 ECZEMATOUS AFFECTIONS. 

the heat of the head and exposure to the air, they undergo partial de- 
composition, and exhale a fetid, sickening odor, of the most disgusting 
kind. Among the children of the poor and destitute, lice often form in 
abundance, and add to the repulsive character of the disease. At first, 
the crusts are somewhat soft and moist, from the percolation thix)ugh 
them of the fluid exuded beneath; but as they become more abundant 
and thicker, their outer surface becomes drj' and sometimes very fri- 
able. The secretion from the inflamed surfaces often makes its way 
under the crusted mass above, and, flowing down over the forehead and 
behind the ears, irritates the parts that were before healthy, and thus 
extends the disease. 

When the crusts are removed by any means, the surface of the erup- 
tion is found to be red, shining, wet. and discharging an abundant puru- 
lent or sero purulent fluid, which escapes from minute excoriated points, 
dotted thickly over the inflamed scalp. The scalp is at the same time 
tumefied, tender to the touch, and abscesses may form beneath it. The 
lymphatic glands, as the occipital, submental, or cervical, are frequently 
enlarged, and at times suppurate. 

When the disease has lasted a considerable length of time, it tends 
to assume a chronic form. The inflammatory action extends to the 
hair-follicles, and often occasions partial loss of hair over larger or 
smaller surfaces. This kind of alopecia is not, however, permanent. 
The hair-bulbs are not destroyed, but merely inflamed, so that the hair 
grows again after the cure of the disease. The tissues of the scalp re- 
main thickened, but the amount of the secretion diminishes; and the 
painful irritation and itching are less troublesome. Under these cir- 
cumstances, the crusts are less thick and massive; they become lighter, 
thinner, and are more easily detached. The epidermis is dry, uneven, 
and rough, and there is a continual desquamation of fine furfuraceous 
particles, constituting a form of pityriasis capitis, or of epithelial scales 
of various sizes, resembling a case of psoriasis. 

On the face {Eczema faciei)^ the disease usually shows itself first on 
the forehead and cheeks, to w^hich parts it may remain limited, or 
whence it may extend to the lips, chin, ears, and neck. The nose and 
eyelids are seldom attacked, though we have occasionally seen the upper 
eyelids slightl}^ affected. 

The disease begins by the appearance of minute vesicles or sero-pus- 
tules on a patch of reddened and slightly swollen skin; there is also 
excessive pruritus. When the eruption is scanty, and rather vesicular, 
and the degree of inflammation slight, the cuticle breaks, and there is 
a discharge of a thin, turbid, serous fluid, which dries into delicate 
scales, or thin lamellated crusts. 

When the accompanying inflammation is more severe, however, the 
eruption is more truly pustular, the pustules being numerous and rather 
large, and the discharge copious, so that when the formation of crusts 
is not interfered with by topical applications, or by the scratching of 
the child, large portions of the affected surface become covered with 
thick yellowish, brownish, or brownish-red crusts, w^hich present the 



SYMPTOMS OF ECZEMA FACIEI — DURATION. 903 

general appearance of a mass of incrustation, broken by cracks and fis- 
sures into portions of very irregular size and shape. 

In the milder cases, when the scales drop off, the skin may appear 
reddened and moist, or may seem to be covered with a very delicate, 
shining epidermis, which is perfectly dry or presents tiny drops of 
serum or minute cracks. In the more severe cases, if the crusts are de- 
tached from any cause, the skin beneath appears red, swollen, inflamed, 
and wetted with a more or less abundant sero-purulent fluid, sometimes 
mixed with blood, that oozes from numerous small points on the ex- 
coriated and inflamed surface. The eruption is attended with severe 
itching and smarting, to relieve which the child often tears the affected 
surface with the nails, so as frequently to remove the crusts, wound the 
skin beneath, and cause more or less bleeding from the part. 

In this more severe form, when the discharge forms a thick discol- 
ored scab covering the scalp or face like a mask, the disease has re- 
ceived the names of porrigo or impetigo larvalis, which are less accu- 
rate than eczema larvale. It corresponds to the impetigo figurata, as 
met with in other parts of the body. 

When the eruption is more scanty and developed in small groups on 
the scalp alone, the discharge is less copious, and soon concretes into 
dry, friable, brownish crusts of irregular shape, some of which are very 
adherent, matting together a larger or smaller number of hairs, while 
others are broken into small and dry fragments, which have been com- 
pared to particles of mortar dispersed among the hair. Many of the 
pustules in this variety are formed at the base of the hairs, so that 
these j^articles of crust, being pierced by the hairs, have somewhat the 
appearance of a string of rude beads. This form of the disease has 
been known as tinea, or impetigo, or porrigo, granulata; but for the 
sake of uniformity, it might be styled eczema granulatum. It corre- 
sponds to the impetigo sparsa, as met with on other parts of the body. 

Eczema larvale, whether confined to the scalp or face or existing on 
both parts at once, causes, when it exists in the acute form, much dis- 
tress and annoyance to the child. The heat and tension of the part, 
and particularly the itching, occasion much restlessness and irritability; 
they make the child cross and peevish, disturb its sleep, and sometimes 
cause slight febrile attacks, which debilitate and injure the health. In- 
deed, when the disease has lasted a considerable time, it often induces 
extreme anaemia and impairs severely the general nutrition of the child. 
In other cases, however, the general health remains perfect, — all the 
functions of the body going on well, notwithstanding the local distress 
and irritation. The lymphatic glands situated behind and in fi-ont of 
the ear, and those on the back and front of the neck often inflame, en- 
large, are frequently hard and painful to the touch, and in a few in- 
stances suppurate, though the latter occurrence is not frequent. 

The duration of eczema larvale is very variable in different cases. 
Mild cases, and particularly those in which the eruption is confined to 
a limited extent, often get well, or are readily cured in two or three 
months. When, on the contrary, the disease is severe and extensive, 



904 ECZEMATOUS AFFECTIONS. 

the duration is much longer, seldom less, according to our experience, 
than several months or even one or two years. In most cases, how- 
ever, the intensity of the disease varies from time to time, so that at 
one period it may seem to be subsiding rapidly, or it may even disap- 
pear almost, or be very greatly ameliorated, only to break out again 
with renewed violence under the influence of some exciting cause, as 
the cutting of new teeth, some change in the weather or season, or 
some alteration in the health of the child which cannot be explained. 
This affection is, as already stated, almost entirely confined to the age 
of dentition. The disease often begins some months before the appear- 
ance of the first teeth, and though it generally ceases or is cured before 
the termination of dentition, we have known it to run on unchecked 
three months after the conclusion of that process and then to be re- 
moved only by medical treatment. 

Eczema granulatum is comparatively a slight disorder, and is usu- 
ally much more under the control of remedies and of much shorter du- 
ration. 

There is a local variety of eczema which requires a brief allusion. 
It is known as eczema tarsi and affects the edges of the eyelids, espe- 
cially in strumous children, in whom it is often associated with stru- 
mous ophthalmia. It is attended wuth the formation of pustules at the 
openings of the hair-follicles, itching, thickening of the eyelids from 
infiltration, the formation of crusts, and a tendency to adhesion of the 
edges of the lids together, especially in the morning after they have 
been in contact during sleep. If not cured by appropriate treatment, 
it frequently leads to distortion of the hairs, which assume abnormal 
directions in their growth, and to inversion or eversion of the lids. 

Eczema impetiginoides also presents itself in other parts of the body 
under the same two forms of impetigo figurata and sparsa which have 
been described as occurring on the head. We have, indeed, more than 
once alluded to the tendency of eczema in children to develop itself in 
different parts of the surface, at times occupying almost the entire cu- 
taneous surface, and presenting all its varieties at one and the same 
time. 

Impetigo figurata, when seated on the trunk or limbs, usually pre- 
sents a large eruptive surface. On the arms we have seen it extend 
from the shoulders to the hands, and, as a general rule, it has been 
most severe on the outer portions of the limbs. On the trunk and 
lower extremities it has usually affected surfaces of much less consid- 
erable size, and has commonly appeared in a patch of an irregularly 
oval shape, and of four, five, or six inches in diameter. 

In these localities it presents much the same aj^pearances as those al- 
ready described in the account of eczema capitis. 

Impetigo sparsa, which is the scattered form of the eruption, is quite 
a common affection in children of all ages. It differs from impetigo 
figurata in the arrangement of the pustules, which, instead of being 
confluent or grouped closely together, appear singly or in small clusters. 
It most frequently appears on the face and scalp, but is also met with 



DIAGNOSIS. 905 

on the extremities, being not unfrequent in children, according to Wil- 
son, on the hands and feet. 

The eruption appears as small yellow pustules, seated upon an in- 
flamed base, and attended with more or less itching. The patch fre- 
quently presents a surrounding circle of confluent vesicles or phlyctenae. 
The pustules soon break and discharge a sero-purulent fluid, which 
hardens into a rugous, more or less projecting, friable crust, seeming 
to consist of diff'erent layers superimposed one upon the other. When 
the crusts fall, or after their removal by topical means, there remains 
beneath an inflamed surface, which may be either excoriated, giving 
issue to additional fluid and a renewal of the crusts, or dry, and disap- 
pearing little by little by the gradual fading away of the red color of 
the spots. 

Eczema Chronicum. — Eczema infantile, if left to itself, has no natural 
tendency to cure, but usually becomes chronic, as in the adult. 

When the disease passes into this form, no matter what may have 
been the original type of the eczema, the eruption gradually assumes 
uniform and characteristic appearances. The various forms which have 
already been described are then to be regarded as varieties of acute 
eczema, while the chronic form is common to them all, and represents 
the condition into which all the acute varieties may merge. 

The skin in chronic eczema is either very much inflamed and thick- 
ened, presenting excoriations with deep cracks and fissures, which pour 
out an abundant ichorous secretion, or, more frequently, the inflamma- 
tion is less severe, there being much less heat, redness, and infiltration 
of the skin, fewer excoriations and cracks, and a smaller amount of 
effusion. The affected surface is, in these cases, dry and parched, and 
constantly throws off a fine furfuraceous desquamation, as in pityriasis, 
or scales of dried cuticle of various sizes, as in psoriasis. 

This form is most common on the scalp, behind the ears, about the 
neck and upper part of the trunk, and in the flexures of the joints. It 
usually lasts for months, and is difficult of cure. It is attended with 
severe itching, which is sometimes so troublesome as to occasion the 
most distressing and uncontrollable i .stlessness at night. 

Not rarely also, on the application of any exciting cause, the erup- 
tion will spread from the spots where it has been lurking in the chronic 
form, and invade more or less of the surface, assuming all the appear- 
ances of acute eczema. 

Diagnosis. — It must be borne in mind, in making the diagnosis of 
eczema, that its characteristic symptoms, which are present in varjdng 
j^roportion in nearly every case, are redness and infiltration of the 
skin, attended with marked itching; and exudation on the surface, with 
the formation of crusts. 

Eczema simplex when seated on the hands and between the fingers, 
ma}^ be mistaken for scabies. The distinction can, however, be made 
by attention to the following points : the vesicles of eczema are flat- 
tened and aggregated; in scabies they are acuminated, isolated, and 
entirely distinct. There will also be frequently found, in scabies, vesi- 



906 . ECZEMATOUS AFFECTIONS. 

cles on the bips where the hand of the nurse from whom the child has 
caught the disease has been placed to support it. In scabies, also, the 
vesicles present little red lines, running off from their margins, and 
marking the course taken by the acarus; and lastlj^, in that disease 
careful search w^ill almost always enable us to detect the insect or its 
ova, which are infallibly characteristic of the disease. 

From sudamina, with which eczema vesiculosum might perhaps be 
confounded, the latter disease maj^ be distinguished by the facts that 
the vesicles constituting sudamina are much larger, that they are dis- 
crote and scattered, that they are associated nearly always with pro- 
fuse perspiration, and that they are unaccompanied by an inflammatory 
state of the skin or by itching. 

Eczema impetiginoides, especially when affecting the scalp, might 
possiblj^ be mistaken for favus, from which, however, it maj^ readily be 
distinguished by the facts that, in the latter disease, the pustules are 
imbedded in the epidermis, and that the crusts present a peculiar bright 
yellow color, and are of an umbilicated or cup-like shape. 

Favus is also followed by incurable alopecia and is contagious, and 
microscopic examination wnll detect the peculiar fungus, the achorion, 
npon which it depends, in all of which circumstances it differs entirely 
from eczema. 

Prognosis. — Eczema infantile is rarely dangerous to life, though it 
sometimes occasions much distress to the health by the suffering, irri- 
tation, and especially by the loss of sleep, which it entails. In one in- 
stance, however, that came under our observation, of verj^ severe eczema 
larvale combined with extensive impetigo figurata, in a child a few 
months old, the disease ended fatally some wrecks after the child had 
been put under the charge of a homoeopathic practitioner. 

In the prognosis given by the physician, especiall}^ in the instance of 
extensive eczema pustulosura, he should never forget to refer to its 
probably long duration, and to its disposition to return even after an 
apparent cure has been effected. It often lasts, in this way, for many 
months, and sometimes for one or two years or even longer. This diffi- 
culty of cure, and obstinate tendency to recur, are often owing to its 
dependence on some constitutional disturbance, or upon derangement 
of the digestive system. It ought, therefore, to be looked upon as the 
expression of a general disorder; and its cure will at times be found to 
depend upon the removal of the constitutional fault. 

It is on this account that the opinion has long been popularly enter- 
tained, that extensive eczema should not be treated by severe local 
remedies, since, if suddenly arrested by such means, the disease might 
fall with all the greater severity upon parts more important to life. 

We no longer, how^ever, attach any importance to this popular ap- 
prehension, and alwaj'S endeavor to secure as rapid a cure as possible, 
by appropriate general and local treatment. 

Treatment. — The remarks which have been already made in connec- 
tion with the causes and constitutional character of many skin diseases, 
will readily suggest the indications which are to be followed in treat- 



INTERNAL TREATMENT. 907 

ment. It is necessary to remove the constitutional disturbance which 
may be the essential cause of the affection, to allay the local distress, and 
to promote the healthy vigorous nutrition of the skin. These principles, 
vrhich guide the practice of most dermatologists, are especially insisted 
on by Mr. Erasmus Wilson, who gives to elimbiation the first place; to 
alleviation of local distress the second ; and to restoration of power the 
third. There are, however, some high authorities who regard the con- 
stitutional treatment in cases of eczema as of very secondary impor- 
tance, and rely almost exclusively upon local measures. Our own ob- 
servation has convinced us that the most rapid and certain cures can 
only be effected by a judicious combination of general and local reme- 
dieS; either of which, however, may, under special circumstances^ as- 
sume peculiar and paramount importance. 

The general treatment of eczema must depend on the state of health 
of the patient at the time, on the extent and activity of the eruption, 
and on its acute or chronic chai'acter. 

In mild cases which show but little disposition to extend, and are 
not attended by much irritation, regulation of the child's diet, and the 
use of the most simple bland applications, will be sufficient. 

When the disease is more extensive and attended with much irrita- 
tion, it is necessary to examine carefully into the state of the digestive 
function, and if this be in any way disordered, to endeavor to restore it 
to a more healthful condition. 

When the child is teething, the gums ought to be examined, and, if 
found swelled or inflamed, they should be lanced as often as necessary. 
The diet must be properly regulated, the food being changed if that 
which has been previously taken is found not to be well and completely 
digested. 

Constipation, if it be present, must be overcome by altering the diet, 
or by the administration of rhubarb, sm.all doses of magnesia, Eochelle 
salts, or sulphur. Purgatives have been strongly recommended by some 
writers in the treatment of eczema pustulosum, but we should advise 
their use only when constipation is present, and in hearty, vigorous 
children. In most cases, the gentlest laxatives, given merely to regu- 
late the bowels^ are to be preferred. 

If there are evidences of acidity of the stomach, it is well to employ 
some of the various preparations of the alkalies. 

So also when diarrhoea is present, it should be treated by attention 
to the diet; and by the administration of a weak castor-oil emulsion, 
containing small quantities of laudanum, when the stools are feculent, 
but small, frequent, and attended with griping; when they are thin 
and watery, greenish, and composed in part of mucus, the following- 
prescription will often prove very useful: 



R. — Tr. Krameriae 
Tr. Opii, . 
Sodte Bicarb., 
Syrup Zingib. 
Aquae, 



gtt. vj. 
f5ij.-M. 



S. — A teaspoonful two or three times a day, for children of one and two years old. 



908 ECZEMATOUS AFFECTIONS. 

When the eruption has persisted for some time, and tends to become, 
or has actually become, chronic, resort must be had to remedies which 
are capable of modifying the constitutional condition of the child. In 
many such cases, the child shows evidences of impaired nutrition, and 
is weak and debilitated ; so that the remedies clearly indicated are 
those which will tend to invigorate the general health and aid in the 
restoration of power. 

The remedy which extensive experience has led us to regard as the 
most useful in all such cases of chronic eczema is arsenic. The prepa- 
ration of arsenic which is best adapted for administration to children is 
Fowler's solution ; which we are in the habit of giving in combination 
with iron, as in the following formula: 

R- — Liq. Potassae Arsenitis, . . . . tt^ xvj ad xxxij. 
Yin. Terri Amari, 
Syr. Tolutani, aa, . . . . . f^j. 

Aq. Carui, f^ij. — M. 

Dose. — A teaspoonful thrice daily, directly after food, for an infant from six months 
to a year old. 

We have never known any serious inconvenience to follow the ad- 
ministration of this remedy, the only annoying symptoms occasionally 
produced being slight gastric irritation and diarrhoea, and a little puffi- 
Dess of the eyelids. By giving it immediately after taking food and 
properly diluting it, it rarely causes any gastric irritation, and even 
should it do so, the symptoms rapidly disappear if the remedy be tem- 
porarily suspended, or given in a smaller dose or less frequentl}^. The 
mother or attendant should, therefore, be carefully instructed to in- 
stantly suspend its administration upon the appearance of any disturb- 
ance of digestion. The puffiness of the eyelids, which is one of the 
earliest and most characteristic symptoms of the physiological action 
of arsenic, is of no alarming import, and the remedy need not be in- 
stantly suspended on account of its appearance: though it is more pru- 
dent, at least, to reduce the dose and frequency of administration, and 
to watch carefully for the occurrence of any further signs of the over- 
action of the drug. 

The period of continuance of this treatment must depend upon the 
state of the eruption, and the manner in which the arsenic is tolerated; 
if necessary, however, and if it causes no gastric irritation, it may be 
continued for many weeks or months. 

•In case.s which persist despite local treatment and the internal ad- 
ministration of arsenic, we have frequently found the use of cod-liver 
oil followed by marked benefit. It may be given combined with the 
arsenic, or, if the stomach will not tolerate it in an undisguised form, 
in the form of an emulsion with aromatics, as recommended at page 
366. 

In cases attended with marked anaemia and debility of constitution, 
associated with a scrofulous tendency, we have obtained good results 
from the administration of the syrup of the iodide of iron. This may 



LOCAL TREATMENT. 909 

be given in combination with the compound syrnp of sarsaparilla, in the 
dose of from gtt. ij to gtt. v of the former, diffused in from a quarter to 
a half teaspooufal of the latter, three times a day, for children of one 
or two years of age. 

It is recommended by some authors to administer calomel. in con- 
siderable and frequently repeated doses in severe eczema. Mr. E. Wil- 
son advises 1 gr. of calomel rubbed down with 1 gr. of white sugar or 
sugar of milk, as the dose for the youngest infant; for a child one year 
old, a grain and a half; for a child two years old, 2 grains; this dose 
being repeated once a week or oftener, according to circumstances. 
"We have not, however, found any necessity for employing calomel as 
an element of our regular treatment, resorting to minute doses of it or 
of blue pill only when the stools are whitish or clay-colored and offen- 
sive; under which circumstances it has almost always been productive 
of good effects. 

The diet should be nutritious and strengthening, but, at the same 
time, light and of easy digestion. 

If the appetite is weak and capricious, tonic remedies, as tincture of 
bark, or quinia, in combination with the ferruginous preparation em- 
ployed, ought to be administered. 

In rare cases, where the patient is of full habit, of gross develop- 
ment, and of florid complexion, the diet must be somewhat restricted, 
and a moderate use of cathartic remedies, as small doses of saline 
laxatives, of blue pill and extract of taraxacum, or of sulphur, resorted 
to. 

Local Treatment. — In mild cases, when the patches of eruption are 
small, and with very little disposition to extend, and the degree of in- 
flammation is slight, a cure may often be obtained with great ease by 
the application, twice or thrice a day, of an ointment composed of one 
part of ung. hydrarg. nitratis to three or four parts of simple cerate, or 
lard; of weak tar ointment; or of the benzoated oxide of zinc ointment, 
as recommended below; or it may even be sufficient simply to wash 
the eruptive patches with cool water several times a day, and to anoint 
them in the evening with ointment of cucumbers. 

When the disease is attended with much irritation, the application of 
compresses repeatedly wet with cold water, or with some emollient de- 
coction, as of marshmallow root, flaxseed, sassafras pith, or slippery- 
elm bark, or the use of warm bread and water poultices, are frequently 
of the greatest service in reducing the heat and irritation, and arrest- 
ing the progress of the eruption. 

The compresses must be repeatedly wetted with the cool applications, 
to prevent the temperature of the liquid from being raised by the heat of 
the body. They may be retained upon the part for several hours at a 
time, or throughout the day, as they nvdy be found to suit the eruption, 
and during the night may be substituted by a dressing of benzoated 
oxide of zinc ointment. 

When warm, moist applications, as poultices, are employed, they 
should always be covered with oiled silk to prevent them from drying. 



910 ECZEMATOUS AFFECTIONS. 

The application which we have used with most marked and uniform 
advantage, and which we believe to be the one best adapted to the forms 
of acute eczema, is the benzoated oxide of zinc ointment/ applied in 
the manner directed by Mr. Erasmus Wilson. 

He directs "that the ointment should be applied abundantly, and 
gently distributed upon the surface until every part of the eruption has 
a complete coating; the ointment should be applied night and morning, 
and if accidentally rubbed off, or used upon parts exposed to the air 
and friction, it may be repeated more frequently. When once applied, 
the ointment should be considered as a permanent dressing to the in- 
flamed skin, and never removed until the skin is healed, unless special 
conditions arise which render such a process necessary." To secure 
the permanent contact with the skin, he recommends that pieces of 
linen rag, or a small garment of linen, be kept constantly upon the 
parts covered with the ointment. 

In cases where the disease has lasted some time, and the discharge 
has dried, so as to form more or less thick and hard crusts, it is abso- 
lutely essential to get rid of these entirely before any of the applica- 
tions to be hereafter recommended can be efficiently applied. This is 
especially the case in eczema capitis, when masses of scabs have been 
allowed to collect and mat the hair together. The removal of these 
crusts is best effected by the use of thick^ moist, and soft poultices, 
which, when applied to the head, should be inclosed in a fine linen rag, 
in order to prevent the matter of which the poultice may be composed 
from adhering to the hairs. Over the outside of the poultice should 
always be placed an oil silk covering, to preserve it moist and soft. 
The poultice may be made of almost any unirritating material usually 

^ We quote from Mr. Wilson (Diseases of the Skin, 7th Amer. ed., 1868, p. 771), 
the precise directions for preparing this ointment : 

Belt's Formula. 
Unguentum Oxydi Zinci, Bekzoatum. 

B;. — Adipis preparati, ^vj. 

Gummi Benzoini, Pulveris, . . . . . • ,^j- 

Liquefac, cum leni calore, per horas viginti quatuor, in vaso clauso ; dein cola per 
linteum, et aclde 

Oxydi Zinci, Purificati, ....... ^j. 

Misce bene, et per linteum exprime. 

If it be desired to make tins ointment rather more stimulating, we may add a little 
alcohol, as in the following : 

Ukguentum Oxydi Zixci, Benzoatum, cum Spiritu Yini. 

R. — Ung. Oxydi Zinci, Benzoati, ^ij. 

Spiritus Vini rectificati, f^ij. 

Misce, ut fiat unguentum. 

Instead of spirit of wine, spirit of camphor, distilled glycerin, liquor plumbi 
diacetatis, Peruvian balsam, or the juniper tar ointment, may be combined with the 
benzoated ointment of oxide of zinc, in the same proportion as above, one drachm 
to the ounce. 



LOCAL TREATMENT. 911 

employed for such purposes. One of the best is that made of stale 
bread and water, with the addition of a little washed lard or hot almond- 
oil to keep it soft. The water is preferable to milk, as the latter often 
sours soon after being applied. Another excellent poultice is one made 
of ground slippery-elm bark, mixed with a little flaxseed or Indian meal, 
to give it a slightly greater consistence. Each poultice may be allowed 
to remain on the part for three or four hours. 

After the crusts have been entirely removed, and the inflammatory 
condition diminished by means of the emollient applications above rec- 
ommended, the latter may be dispensed with entirely, or during the 
greater part of the day; or they may be used only during sleep, at 
which time they are usually best submitted to b}^ the child. At this 
stage of the disease it becomes proper to make use of different lotions 
and ointments intended to modify the action of the diseased skin. 

The number of local remedies recommended in the books for eczema 
in its various forms is, however, so enormous, that we shall refer only 
to those which we have ourselves made trial of and found useful, or 
which come from such sources as entitle them to our attention. 

The choice between the use of lotions or ointments must depend very 
much upon trials made in each particular case, since it will be found 
that some are irritated by all, even the mildest ointments, and bear lo- 
tions only, while in other instances exactly the opposite occurs. 

Amongst the lotions, the most soothing and beneficial are a weak so- 
lution of borax containing morphia; weak lead- water; a sulphuro-alka- 
line lotion, as the following: 

R. — Potass. Carbonat. ^ss. 

Sulph. Sublimat., 3J. 

Aquae Fluvial., ........ fgviij. 

Ft. Sol. 

Or weak solutions of bichloride of mercury, gr, ss. to fjj, as Yan Swie- 
ten's liquor : 

R. — Hydrarg. Chloridi Corros., gr. xviij. 

Alcohol, fjiij- 

Aquse Destillat,, f^xxix. 

Ft. Sol. 

These lotions may be applied on pledgets of lint wetted with them, 
or, if such prolonged applications prove irritating, they maybe used by 
merely washing the part with them for a quarter of an hour each time. 

We have ourselves usually found that ointments afl'ord more relief in 
sach cases, and the one which we think the most appropriate, is the 
ointment of the benzoated oxide of zinc, rubbed down with a little alco- 
hol. Among the other ointments highly recommended, are those con- 
taining oxide of lead or calamine; or citrine ointment, diluted with two 
or three parts of simple cerate. 

When the eruption is confined to a rather small surface and is not 



912 ECZEMATOUS AFFECTIONS. 

very acute and rapid in its progress, or when the activity of the in- 
flammation has been somewhat subdued, more powerful local remedies 
may be employed. Among these may be mentioned a saturated solu- 
tion of borax in dilute acetic acid; stronger solutions of corrosive sub- 
limate ; solutions of nitrate of silver, of from 2 to 10 grains to the ounce ; 
or such ointments as the citrine, either pure or mixed with an equal 
amount of lard or simple cerate; or, ointments containing protiodide 
of mercury : 



R.— Hydrarg. Protiod., .... 


. gr. xij. 


Cumphorse, ..... 


• gr- V. 


Axungise, 


. gj— M. 


Apply twice daily. 




Or calomel : 




R.— Hydrarg. Cblor. Mitis, 


■ BJ. 


Camphors, 


• gr. V. 


Glycerinse, 


• f3J- 


XJngt. Aquse Eosae, .... 


• f3J— M. 



Tar ointment, or either of the zinc ointments, may also be used. 

After the activity of the inflammation has been diminished by treat- 
ment or by time, and the disease tends to pass into a chronic form, it 
becomes necessary to make use of more stimulating applications than 
those just named. The best of these remedies are those which contain 
alkaline substances, tarry substances, or mercury. 

The remedy from which we have obtained the most beneficial effects 
in such cases, is the spiritus saponatus kalinus of Hebra, which is pre- 
pared by dissolving soft (potash) soap in alcohol (in the proportion of 
two parts of the soap to one of alcohol), filtering the solution, and scent- 
ing it with spiritus lavandulse, or any other aromatic spirit : 

R. — Saponis Mollis, . . . . . • ^^j- 

Alcoholis, ....... f^j. 

Misce, et cola. 

In the use of this application it is essential, as directed by Hebra, 
that the soap should be firmly rubbed into the eruptive patch by means 
of a piece of flannel or a brush, till the accumulated masses of epider- 
mis are removed, and a little blood is seen to ooze from the red base 
which has thus been exposed. 

Other ointments and lotions containing alkaline substances are also 
recommended, such as those containing carbonate of potash, gr. xx to 
XXX to ^j of lard (Neligan), or caustic potash, gr. ij to gr. x to f^j of 
water. This latter application is especially useful in cases where the 
eruption is confined to limited patches, and is attended with much in- 
filtration of the skin. If the stronger forms of the salution are used, 
they should, after being applied quickly by means of a brush, be washed 
off by a large brush wetted with pure water. 



HERPES. 913 

Tarry applications also are among the most useful in the chronic form 
of eczema. The}- may be made in the form of ointments, as the offici- 
nal tar ointment, or the following, recommended by Eilliet and Barthez 
as successful in their hands: 

R.— Vini Opii, f^ss. 

Picis Liquidee, B'^jss. 

Axungine, 5J-— ^I- 

Or, they may be combined with an alkali, as soft soap, as is done in 
Hebra's tinctura saponis viridis cum pice; which is made by adding 
one part of tar to three of the spiritus saponatus kalinus. 

The tarry ingredient in these may be either common tar ; oil of cade 
(oleum cadinum, hnile de cade), a product of the dry distillation of the 
wood of the juniperus oxycedrus ; oleum fagi, obtained from the beech ; 
or oleum rusci or betulce, w^hich comes from the bark of the betula alba. 

When used in the form of soap, it should be rubbed firmly over the 
affected surface, or even be allowed to dry on. 

The forms of mercury best adapted to this stage are the nitrate, the 
protiodide, and the mild chloride, which may be combined w^ith lard in 
a larger proi^ortiou than that recommended for an earlier stage of the 
disease. 

In cases of eczema tarsi, attended with infiltration of the eyelids, 
McCall Anderson recommends that the eyelashes should be extracted, 
the eyelids everted and a solution of caustic potash gr. v or x to f^j ap- 
plied and quickly w^ashed off by a large brush. Care should be ob- 
served in case the edges of the eyelids are adherent in the morning, 
not to separate them rudely, but to moisten them with tepid water or 
milk and water, so as to soften the crusts. Afterwards an application 
of citrine ointment, diluted with about two parts of lard, should be 
made along the edges of the lids night and morning. 



, 



AETICLE II. 

HERPES. 

Definition; Varieties; Frequency. — Herpes is a non-contagious 
cutaneous disease, characterized by an eruption of vesicles assembled 
in groups on inflamed surfaces, of irregular size and shape, which are 
separated from each other by perfectly healthy portions of skin. The 
disease is usually acute in its course, seldom lasting more than two or 
three weeks, but it is not, as a general rule, accompanied by any severe 
constitutional symptoms. The separate vesicles composing the erup- 
tion last about ten days, and then disappear by the absorption of their 
contents, by the drying up of the contained fluid without rupture of the 

58 



914 HERPES. 

vesicles, or by the rupture of the vesicles, the escape of the fluid, and 
the formation of thin, brownish, or yellowish scabs. 

There are several different varieties of herpes which have been well 
divided by Mr. Wilson into two groups, the phlyctenoid and circijiate. 
The phlyctenoid group is characterized by the irregularity of form ex- 
hibited by the eruption, and includes the variety called herpes phlj^c- 
tenodes, and the local forms, called according to their seat, labialis, 
nasalis, palpebralis, auricuUxris, prsepntialis, and pudendalis ; whilst the 
circinate group is characterized by the arrangement of the vesicles in 
circles, and includes the herpes zoster, and iris. Of these different va- 
rieties we shall describe, as of importance in children, only the phlyc- 
tenodes, zoster, and iris. Herpes circinatus, formerly included in this 
group, will be found described in the article on tinea. 

Herpes is quite a frequent disease in children, though one rarely of 
any considerable importance. 

Causes. — The causes of herpes are often obscure and uncertain, and 
in many cases entirely inappreciable. The disease is most common in 
persons who possess a delicate and irritable skin. The most frequent 
and most clearly ascertained cause is some disturbance of the digestive 
functions, and when there exist, in connection with this condition, irri- 
tations or inflammations of the respiratory mucous membrane, it is es- 
pecially apt to be developed. Herpes phlyctenodes often follows 
exposure to a hot sun, while herpes labialis is frequently caused by ex- 
posure to a cold wind, especially when this occurs immediately after 
leaving a heated room. The latter variety also frequently accompanies 
coryza, angina, and stomatitis, and appears often as a critical eruption 
in the course, and particularly at the termination, of fevers, catarrhs, 
and visceral inflammations. 

The usual exciting causes of the disease are irregularities in diet, ex- 
posure of the body while in a heated state to cold and damp, local irri- 
tants, malarial disease, and bilious disorders of all kinds. 

Herpes Phlyctenodes. — This variety of herpes, unlike the other 
forms of the disease, may appear upon any part of the cutaneous sur- 
face, and does not assume a determinate shape. It may appear, indeed, 
upon several parts at the same time. It is usually, however, met with 
upon the upper parts of the body, and particularly the cheeks, neck, 
•chest, and arms. It is rare to observe it on the lower extremities. 

We believe it to be a rare affection amongst the children of families 
in easy circumstances. The only examples that we have seen have 
been the result of poisoning by the different kinds of Toxicodendron. 

Symptoms. — The eruption appears in the form of vesicles, usually of | 
yevy small size, looking like mere points, or attaining sometimes the 
size of a pea, which are seated in groups or clusters on inflamed patches 
• of the skin, varying in size from that of a dollar to that of the palm of j 
the hand. Sensations of heat, smarting, and itching, are often felt in 
the part where the eruption is about to show itself; and within a day, 
usually, after these symptoms have been observed, or without them J 
the disease makes its appearance, exhibiting one or more red and in- 



SYMPTOMS OF HERPES LABIALIS AND ZOSTER. 915 

flamed surfaces, of an irregular or rounded shape, dotted over with pro- 
jecting, globular vesicles, which are hard, resisting, and, on the first 
day, transparent, but which become, in the course of a day or two, 
turbid or lactescent. The red color of the eruptive patch generally ex- 
tends a short distance bej'ond the vesicles : the integument between the 
different patches retains, however, in all cases, its healthy color and 
character. A sense of smarting and itching accompanies, as well as 
precedes, the eruption. On the second day of the eruption, the num- 
ber of vesicles gradually increases, and they become full and distended. 
About the third or fourth day, the vesicles have become very turbid, and 
they begin to shrink. About the seventh or eighth day, they are usu- 
ally transformed, bj^ the drying up of their contents, into thin, brown- 
ish crusts, which fall off by desquamation about the tenth or twelfth 
day. There also remains, for a few days after the disappearance of 
the eruption, some redness of the surface, which subsides little by little. 

This variety of herpes is never accompanied by constitutional symp- 
toms of any severity. A very slight febrile reaction, some languor, 
loss of appetite, and thirst, are the only ones worthy of note. 

Herpes Labialis. — This is the most frequent of all the varieties of 
the disease. It is, as its name imj^lies, a disease of the lips. Usually 
it is seated upon the line of junction of the mucous membrane with the 
integument; but it may affect either the former or latter alone. Though 
generally confined strictly to the lips, the eruption, in some instances, 
extends to the cheeks, chin, or alse of the nose. 

The disease begins generally with redness, heat, smarting, and pain- 
ful tension of the portion of the lip upon which the eruption is about to 
appear. After a few hours, or a day, vesicles begin to show themselves 
upon the inflamed spot, and there is then observed a red, swollen, and 
shining point, upon which is seated a group of vesicles. The tumefac- 
tion and redness commonly extend some distance beyond the vesicles. 
The latter develop themselves rapidly, until five or six small, rounded 
vesicles, filled with a transparent fluid, are seen. The vesicles remain 
solitary, or several may unite together to form one of considerable size. 
After the complete development of the eruption, the burning pain which 
existed at first commonly subsides. The contents of the vesicles soon 
become turbid and lactescent, and are converted, by the third or fourth 
day, from a serous into a sero-purulent fluid, at which time, also, the 
accompanying redness and swelling have, in great measure, disap- 
peared. Soon after this, brownish crusts are formed by the drying up 
of the fluid of the vesicles, and these drop off usually about the seventh 
or eighth day. A slight redness remains for a short time at the point 
of eruption^ and then disappears entirely. 

Herpes Zoster. — This variety of herpes is known also by the names 
of Zona and Shingles. It is of much less frequent occurrence, in this 
city, in children, than either the herpes labialis or circinatus. Wo have 
never as yet seen a case of it in a child, though Eilliet and Barthez 
state that they met with this form and the heri3es labialis more fre- 
quently than any other. The peculiarity of the disease cons'sts in the 



916 HERPES. 

fact that the eruption appears in the form of a half zone, surrounding 
half the hody, whence its name, herpes zoster, the latter word signify- 
ing a girdle or belt. 

The most frequent seat of zona is the base of the thorax, the disease 
extending usuall}', in the form of a cincture, from the mesial line in 
front to the same point behind. It may, however, be developed either 
above or below the part just named, and, under these circumstances, is 
apt to extend towards or down the arm, or towards the thigh and 
down the leg. Still more rarely, it has been observed upon the neck, 
face, or scrotum. There is some doubt as to which side it is most dis- 
posed to attack. The half zone formed by the eruption is not com- 
posed of a continuous line of vesicles, but is made up of distinct patches 
of eruption, all following the same general direction, but divided from 
each other by portions of healthy integument. The eruptive patches 
may be very closely approximated, or they may be separated by con- 
siderable s^^aces of skin untouched by the disease. 

The disease is acute in its character, lasting, as a general rule, from 
one to three or four weeks. 

Shingles appear first, after some previous smarting and burning in 
the skin, in the form of irregular patches of a vivid red color, more or 
less widely separated from each other, and developed, one after the 
other, until one-half the body is girdled by the eruption. In some in- 
stances, the disease appears simultaneously at the two extremities of 
the zone, and is terminated by the gradual formation of successive 
patches between these two points. Soon after the appearance of the 
inflamed patches, numerous small, white projections can be seen, by 
careful examination, upon the red surfaces; these increase rapidly in 
size, and are soon converted into distinct, transparent vesicles. The 
vesicles augment in size, and arrive, in the course of three or four 
days, at their fullest development, when they are about as large as 
small or large peas, or, in some few instances, much larger. At this 
stage of the eruption, the red surface upon which each group of vesicles 
is seated extends a slight distance beyond the patch, thus forming a 
kind of areola. 

After pursuing the course just described during four or five days, 
each group of vesicles begins to subside. The redness of the inflamed 
patch diminishes; the vesicles shrink, and become shrivelled; their 
contents, which were transparent at first, become opaque, and finally 
they dry up and form small, dark-brown scabs, which fall off about the 
tenth or twelfth day, leaving behind reddish spots, which disappear 
little by little. 

The constitutional symptoms of herpes zoster consist usually of slight 
feverishness, languor, and the signs of gastro-inte.stinal irritation. The 
local sj'mptoms are pungent and burning j^ain at the beginning of the 
eruption, and more or less severe tension, and sometimes acute pain, in 
the part upon which the disease is seated, which latter lasts, in some 
instances, throughout the course of the disorder, or even for some con- 
siderable time after it has disappeared. 



DIAGNOSIS — PROGNOSIS. 917 

Herpes Circinatus. — This variety of herpes has been called also ring 
herpes, herpetic ringworm, and vesicular ringworm; it will be found 
described under the name tinea circinata in the article on parasitic dis- 
eases of the skin. 

Herpes Iris. — This is a very rare variety of herpes, and one that we 
have never yet met with in children. It begins with small red spots, 
which are soon surrounded b}" four or five rings of different shades of 
redness. About the second day of the eruption, the central red spots 
present in their centres one or more vesicles, and on the third and 
fourth days, vesicles of very minute size generally appear on the outer 
concentric rings. After two or three days, the fluid contained in the 
central group of vesicles, which was transparent at first, becomes tur- 
bid, and about the fifth or sixth of the eruption, it is absorbed, and the 
disease terminates by a slight desquamation. The vesicles formed on 
the outer rino; undero-o the same chano-es as those described as occur- 
ring on the central ones. In some instances, the vesicles open, and 
their contents escaping, form small, thin, and brownish scales, which 
fall off in ten or twelve days. 

Herpes iris may attack any part of the body, but is most frequently 
developed upon the face, hands, fingers, and neck. 

According to some dermatologists, as McCall Anderson, herpes iris 
is a parasitic disease and merely a form of tinea versicolor. 

Diagnosis. — The diagnosis of herpes is seldom attended with any 
difiiculty. The small size of the vesicles, their globular shape, their 
number, their aggregation upon distinct patches of inflamed integu- 
ment, and the slight degree of constitutional disturbance attendant 
upon the diifcase, all render the eruption unlike any other cutaneous 
affection, and therefore easy of recognition. 

Herpes phlyctenodes might possibly be confounded by an irjcompe- 
tent observer with pemphigus. The recollection that the eruption in 
pemphigus consists of distinct bullae, much larger, of course, than the 
vesicles of herpes, while that of herpes phlyctenodes consists of numer- 
ous vesicles, much smaller than the bullae of pemphigus, and closely 
dotted over isolated red patches, will always serve to distinguish the 
two affections. It might be mistaken also for eczema, when the vesi- 
cles of the latter are disposed, as sometimes, though rarely, happens, 
in groups: The distinction may be made however, by attention to the 
facts that the eczematous vesicles are redder, less elevated, scarcely 
transparent, and that, though arranged in groups, they are confluent, 
whilst in herpes they are always distinct. 

Herpes labialis is not likely to be mistaken for any other eruption. 
Herpes zoster may always be distinguished by the peculiar belted form 
assumed by the eruption. 

There is but one disease with which herpes iris is likely to be con- 
founded — roseola annulata. The entire absence of vesicles in the latter 
affection will always, however, enable us to make the distinction. 

Prognosis. — The 'prognosis of herpes is always fixvorable. It is never 
in itself a dangerous disease, though the variety called zona often 



918 HERPES. 

causes much suffering, and is moreover usually the expression of a 
considerable disturbance of the general health. 

Treatment. — The different varieties of herpes seldom require more 
than the mildest treatment. In all, attention should be paid to the 
general health. The diet must be regulated according to the state of 
the digestive function. When constipation is present, especially if there 
be some febrile reaction at the same time, gentle laxatives ought to be 
administered, such as sulplmr, magnesia, syrup of rhubarb and magne- 
sia, or castor-oil. If the skin be sallow, the tongue heavily coated, the 
breath foul, and the stools scanty and light-colored, or very offensive, 
small doses of blue pill in combination with rhubarb, or followed by 
rhubarb and magnesia, would be the most appropriate remedy. Exces- 
sive or frequently-repeated doses of any purgative ought to be avoided, 
as the debility and gastro-intestinal irritation that so often follow such 
practice, are more injurious than the original disease. 

The local treatment of herpes is important, and is, indeed, in many 
cases, all that is necessary. 

Herpes phl^'ctenodes requires nothing more than mucilaginous lotions, 
an occasional warm bath, or the frequent moistening of the eruption 
with a liniment made of equal parts of lime-water and sweet-oil. 
Herpes labialis, if it demand local treatment at all, may be relieved by 
the use of any mild lip-salve; a very good ointment is one composed 
of equal parts of Goulard's cerate and simple cerate, with a few drops 
of glj^cerin. Mr. Wilson recommends the following ointment : 

R. — Unguent. Flor. Sambuci, ^j. 

Liq. Plumbi, f^j-— M. 

During the early stage of herpes zoster, the local treatment should 
be such as will tend to allay inflammation and relieve pain. These 
effects may be obtained by applying compresses moistened with some 
kind of mucilage, such as barley-water, or decoction of flaxseed or 
slippery-elm bark, or with simple cold water, or with weak lead-water 
and laudanum. When the eruption is followed by excoriations or ulcer- 
ations, and the pain is severe, the latter may be allayed by the use of 
an ointment consisting of equal parts of Goulard's cerate and lard, 
either alone, or containing two or three grains of opium, or half a 
drachm of the watery extract of opium. Underwood recommends, 
when the discharge has subsided, and the scabs have formed and become 
adherent, that they should be anointed twice daily with the ung. hy- 
drarg. ammoniat. 

Herpes iris seldom requires any treatment. If any be determined 
on, it should consist of alkaline lotions, or of water rendered slightly 
astringent by the addition of alum, or sulphate of zinc. 



SCABIES. 919 

ARTICLE III. 

SCABIES. 

Definition; Synonyms; Frequency. — Scabies is a contagions erup- 
tion of the skin, characterized by the formation of papules, vesicles, or 
pustules; the vesicles being pointed, generall}^ discrete, and usually pre- 
senting small red lines, of one or several lines in length, running off 
from them. The eruption is attended with severe itching, and is caused 
partly by the presence in the skin of a small insect, called the acarus 
scabiei, and partly by the scratching which the intolerable itching 
provokes. 

Causes. — Itch is a contagious malady, and is in all probability caused 
only by contact, either immediately with some person laboring under 
the disease, or with articles of clothing worn b}^ an infected individual. 

It is much more frequentlj" met with amongst the poor and destitute, 
whose habits are uncleanly, who live closel}^ ]->acked together in small 
and inconvenient houses, and in whom, therefore, the means of commu- 
nication are more abundant, than amongst the easy classes of society, 
whose habits, and, consequently, liability to contact, are the opposite 
of those just named. 

The disease usually appears in children in from four to five days 
after the exposure to contagion. In healthy, sanguine children, it often 
shows itself within a shorter time — after two days — while in those who 
are feeble and weakly, the period of incubation may be even longer 
than four or five days. 

Symptoms. — The first symptoms of itch appear in the part to which 
the cause, a contagious contact, may have been applied. In infants at 
the breast, it is usually first developed on the hips and thighs, as it is 
those parts that are mOst constantly in contact with the nurses who 
carry the child, and from whom young children generally receive the 
infection. In older children, the disease commonly appears first on the 
wrists and between the fingers, and extends thence more or less quickly 
to the flexures of the elbows, and to the axi-llse and abdomen. It rarely 
or never attacks the face in adults; but in children, even this part is 
not, according to M. Richard, exempt. (Trait. Prat, des Mai. des En- 
fants, p. 590.) 

The disease is always attended with severe itching, which, in infants, 
causes uneasiness and fretfulness, and, in older children, violent scratch- 
ing. The itching is increased by the heat of the bed-coverings, and is, 
therefore, most troublesome at night. The eruption appears in the 
forai of more or less numerous vesicles, which are small, discrete, acumi- 
nated, and transparent at the top. The vesicles are at first of a faint 
rose color, and they contain a viscid, transparent serum. Their number 
is variable, being sometimes very abundant, and at others sparse. They 
either open spontaneously, or are soon broken by the fingers or clothes, 



920 SCABIES. 

and are followed by small, thin, slightly adherent scabs. In some in- 
stances the action of the nails causes slight effusions of blood, which 
dry into small bloody scabs, like those of prurigo, thus embarrassing 
to a certain extent, the diagnosis of the disease. Sometimes, particu- 
larly when the inflammation attendant upon the eruption, or that caused 
by scratching, is marked, there are, intermingled with the psoric vesi- 
cles, pustules of impetigo, or perhaps papules of lichen, which tend 
like the sanguine crusts, just alluded to, to render the diagnosis diffi- 
cult. Indeed it is not strictly correct to define scabies, as was formerly 
done, as a vesicular affection, since the eruption is papular in a very 
large proportion of cases. 

When a recent vesicle is carefully examined, there may generally be 
observed running off from it, in a straight, curved, or zigzag direction, a 
whitish or reddish line, like that produced by the scratch of a pin. This 
line marks the course of the fecundated female of the acarus scabiei in its 
burrowings under the epidermis, and is called the cuniculus, or burrow. 
It varies in length from one or two, to five or six lines. At the point 
where it terminates opposite to the vesicle, there is usually to be seen 
a small rounded projection, deeper in color than the rest of the cuni- 
culus, beneath which lies the insect. The acarus can often be found at 
this spot, and removed, by carefully introducing horizontally under the 
epidermis the point of a small needle, and by manipulating so as to take 
off a small layer of the epidermis. The insect clings to the point of 
the needle, and can then be extracted from its lodgement. 

The number and extent of the vesicles vary greatly in different sub- 
jects. In some they are confined to limited surfaces, while in others, 
and particularly in robust, sanguine children, and in those who are neg- 
lected and imperfectly cleansed, they extend to many different parts, or 
over the greater part of the body. 

Itch occasions in children much irritability and suffering, and when 
neglected may injure seriously the general health, and cause emaciation 
and debility. 

The acarus scabiei is an arachnoid insect, varying, according to Mr. 
Wilson's measurements, between jiy and y'y of an inch in length, and 
between -g-J^ and -g\ of an inch in breadth. It is of a whitish and shin- 
ing color, when examined with the naked eye, of a globular form, and 
is provided w^ith eight legs, four anterior and four posterior. A most 
accurate and minute account of the structure of the insect is given by 
Mr. Wilson in his work on diseases of the skin (7th Amer. ed., p. 739). 
Besides the female, which is found, as before stated, at the extremity, 
the cuniculus contains a varying number of ova, rarely more than twelve 
or fourteen ; there are in addition numerous little oval or round black- 
ish spots, which are supposed to be excrement. These ova are about 
-g-i-g- of an inch broad, and yV^ of an inch in length, though their size 
varies according to their age. After the escape of the acarus the shell 
appears shrivelled, with two slits in it. 

Diagnosis. — The most characteristic marks of itch are the presence 
of the cuniculi and of the insect which causes the disease. If the acarus 



DIAGNOSIS. 921 

or its ova can be extracted from the skin, there will remain, of Gouvse, 
no doubt; and if the ciiniculi be distinct and numerous, the diagnosis 
becomes almost as certain as when the insect itself is obtained. Before 
endeavoring to detect the cuniculi, it is always advisable to make the 
patient wash the part thoroughly. 

In doubtful cases, it has been recommended by Gull and Hilton Fagge 
to search for the ova in the crusts or the thickened and undermined 
cuticle in the neighborhood of the vesicles. In order to detect these, 
a small piece of the crust should be boiled in a solution of caustic soda, 
5ss. to f5j of water, until it is in great part dissolved; the fluid should 
then be allowed to settle, the supernatant part decanted and the deposit 
examined, which will, in cases of true scabies, be generally found to 
contain larvae, ova, or egg-shells. 

When, on the contrarj^, the insect cannot be found, and when the 
cuniculi are absent or not distinct, the diagnosis becomes more uncer- 
tain. The diseases with which it is most likely to be confounded are 
eczema sim^^lex, prurigo, and lichen simplex. From the former ic may 
usually be distinguished with certainty by attention to the following 
points. In eczema the vesicles are flattened, or globular, scarcely raised 
above the surface, and they are collected together in clusters; in itch 
they are acuminated, elevated, and either entirely distinct, or much 
less confluent than in eczema; in eczema there is a sensation rather of 
pricking than itching, w^iilst in itch the sense of itching is severe and 
distressing; and lastly, itch is communicable by contact, whilst eczema 
is never contagious. 

Prurigo begins with papules, which always remain such. The scabs 
in prurigo are small and black, consisting of coagulated blood, caused 
to exude by the rubbing off of the top of the papule; while in scabies 
the scabs are more like thin, yellowish, and friable scales. The seat of 
the two eruptions is different. Prurigo is developed upon the back, the 
shoulders, and upon the extensor surfaces of the limbs; while itch ap- 
pears first about the thighs and buttocks, between the fingers, or about 
the flexures of the joints. Lastly^ prurigo is never, itch always, con- 
tagious. 

Lichen simplex is a papular disease, in which the papules are closely 
agglom.erated, while in scabies the papules, if present, are conjoined 
with vesicles, and are discrete. Lichen sometimes affects the hands, 
and might then be mistaken for itch; but in the former the eruption 
affects the dorsal surface of the hands, while in the latter it appears in 
the interspaces of the fingers. Lichen is never attended, as itch always 
is, by severe pruritus. Attention to these points of difference will 
almost always render the diagnosis of the two diseases very easy and 
certain. 

When, as sometimes happens, scabies is intermingled with other erup- 
tions of the pustular, papular, or vesicular kind, the diagnosis can be 
arrived at with certainty, only by careful attention to the cuiiiculi, or 
by the detection of the insect. When neither of these characteristic 



922 SCABIES. 

conditions are present to mark the true nature of the disease, there will 
alwa3S remain some doubt as to the diagnosis. 

Under these circumstances, however, it is advisable to treat the case 
as one of scabies, since the specific remedies for this affection will not 
be injurious, even if they do not speedily cure the eruption. 

Prognosis. — Itch is a mild disease, which never disturbs the health 
seriously. 

Treatment. — If the inflammation produced by scratching be very 
severe, it may be necessary to allay it by emollient applications, though 
this rarely happens. 

In children as in adults, the best treatment of itch is the use of sul- 
phur by inunction. The ungt. sulphuris of the American Pharmaco- 
poeia, consisting of one part of sulphur to two of lard, should be well 
rubbed into the skin before a fire, morning and evening, for two days. 
The child should be kept in a flannel gown, and in bed, during this 
treatment. On the morning of the third day, the skin may be washed 
clean with soap and water, or by imiTiersion in a warm bath. This plan 
rarely fails to effect a cure. Should it happen, however, to fail, the 
treatment must be repeated. Before the application of this or any of 
the other ointments, the surface should be well scrubbed with soap and 
hot water, so as to cleanse and soften the skin. 

It also increases the efl'ect of the sulphur, to conjoin with it some 
alkaline substance, as in the various sulpho-alkaline ointments and 
lotions, of which the following are among the best: 

Ung. Sulphuris cum Potassa (Wilson). 

R. — Sulphuris Sublimati, . . gj. 

Potassse Carbonatis, ....... ^ij. 

TJnguenti Benzoati, ....... ^v. 

Olei Anthemidis Essentialis, f^ss. — M. 

Hehnerich's Formula. 

R. — Sulphuris Sublimati, gij. 

Potassae Carbonatis, ^j. 

Adipis Preparati, .Iviij. — M. 

Vlemingkx^ s Formula. 

B- — Calcis Yivi, ^^ij. 

Sulphuris Sublimati, .... . . ^iv. 

AquteEontanse, . f^xx. 

Boil in an iron vessel, and stir with a wooden spatula to a perfect union. 

These are all quoted in the proportions directed for adults, which are 
much too active to be applied to the delicate skin of children ; they 
should therefore be diluted one-half at least. 

Anderson recommends the use of oil of cade or tar, combined with 
the sulpho-alkaline ointments. 

As the use of the sulphur ointment is sometimes objected to in pri- 
vate families, on account of its disagreeable odor, various substitutes 



PEMPHIGUS OR POMPHOLYX. 923 

have been recommended. Mr. Wilson states that he found camphor 
dissolved in oil, in the proportion of one drachm to the ounce, answer 
every purpose of eradicating the disease; and Dr. Coley {Prac. Treat, 
on Dis. of Children^ Phil, ed., 101) speaks highly of an ointment com- 
posed of a drachm of iodide of potassium to an ounce and a half of lard, 
of which a little is to be applied all over the body, except the head and 
face, every night. 

Ointments containing carbolic acid or petroleum are also used with 
good effect. 

The use of stavesacre and hellebore has lately been revived, and ap- 
parently with good success; and Anderson highl}' recommends an oint- 
ment made by melting together one part of liquid styrax with two of 
lard. 

The disease rarely requires any constitutional treatment. If, how- 
ever, any complication exist, or the general health be deranged in any 
way, such measures as may be necessary for the removal of either of 
these conditions should be emploj^ed^ in connection with those proper 
for the specific disease. 



CHAPTER III. 



BULL^. 



ARTICLE I. 



PEMPHIGUS OR POMPHOLYX. 



Definition; Synonyms; Yarieties ; Frequency. — Pemphigus is an 
eruptive disease, characterized by the presence on one or several parts 
of the body of more or less numerous bullae of considerable size, nearly 
always isolated, resting upon circular or oval erythematous patches, 
about as large or somewhat larger than the bases of the bullas them- 
selves. The bullae form in the course of a few hours, and contain at 
first a limpid serum, which soon becomes reddish or turbid; they ter- 
minate by desiccation and the formation of thin crusts, or b}^ rupture 
and the escape of their contents, when there remains behind a super- 
ficial ulceration. 

Authors formerly described numerous varieties of this disease, and 
gave to some of them the title of pompholyx. Of late years, however, 
these have been reduced to a few forms, and we shall confine our re- 
marks to those most apt to occur in children. The only variety Avhich 
is really important in children is the pemphigus acutus. The pemphi- 
gus chronicus, a dangerous and not unfrequent variety in old people, 
is so rarely met with in early life, as to make it unnecessary for us to 



924 PEMPHIGUS OR POMPHOLYX. 

describe it. Another species of bullar eruption, formerly called pem- 
phigus infantilis^ is now more properly classed as rupia escharotica, 
under which title we shall give an account of it. 

Pemphigus is not unfrequently met with in young children who be- 
come the inmates of hospitals, almshouses, and foundling hospitals, and 
amongst the poor and destitute classes of large cities. Still it cannot 
be said to be a frequent disease. 

Causes. — The causes of pemphigus are often obscure or entirely in- 
appreciable. It is usually supposed, however, to depend, in children, 
upon the influence of the act of dentition, on disturbances of the gastro- 
intestinal tube brought about by improper food or overfeeding, and on 
general disorder of the nervous system. It is one of the most frequent 
eruptions in congenital syphilis (see p. 872), and is not rarely present 
at birth in such cases. 

Symptoms. — Acute pemphigus may be confined to a very small por- 
tion of the cutaneous surface, or it may aff'ect several regions of the 
body at once. It is usually attended with symptoms of constitutional 
disturbance, which, especially in very j^oung infants, may be slight, 
consisting merely of general uneasiness, languor, and some accelera- 
tion of the pulse; or they may be severe, exhibiting in such cases a 
dry and burning skin, frequent pulse, thirst, and loss of appetite. 

After the above constitutional symptoms have lasted one, two, or 
three days, the eruption makes its appearance in the form of small cir- 
cular red spots, which increase in size, and soon exhibit a bleb or bulla 
rising in the middle or over the whole of the red spot. The vesicle 
commonly appears a few hours after the red patchy and consists of an 
elevation of the cuticle by an effusion of serum beneath it. The bulla 
rapidly distends by the increase of the serous effusion, until it attains 
the size of a pea, a hazelnut, or a large walnut. It is of a circular or 
oval form, and may be confined to the centre of the erythematous sur- 
face on which it rests, being surrounded in such cases by a more or less 
wide red line of inflammation, or it may occupy the whole or nearly 
the whole of the red patch, under which circumstances it entirely con- 
ceals the latter, or is surrounded by a very narrow red ring. The color 
of the areolae around the bullas is very bright during the first day of 
the eruption, while the integument between remains perfectly healthy. 

The fluid contained in the bullae soon becomes turbid; the bullae be- 
come wrinkled, and usuall}^ burst after one or two days, and are re- 
placed by thin yellowish or brownish scabs. The crusts begin to form 
before the redness of the integument has disappeared. In some in- 
stances the bullae do not break, but their contained fluid becomes yel- 
lowish in color, and then turbid; it diminishes by absorption, and, at 
the end of about a week, dries into a thin dark-colored scab. The crusts 
usually fall off in the course of two or three weeks, leaving the skin 
beneath of a reddish color, but in other respects healthy. The whole 
duration of the disease is commonly from one to three weeks, the time 
in each case var3nng with the mode of the eruption; when all the bullae 
appear simultaneously, seldom lasting more than one or two weeks; 



DIAGNOSIS — PROGNOSIS — TREATMENT. 925 

while in cases in which they appear at successive periods, lasting three 
or even four weeks. 

Diagnosis. — The diagnosis of pemphigus acutiis is seldom difficult. 
The large isolated bulla?, seated on inflamed patches of the integument, 
filled with transparent serum, and followed by thin lamellated scabs, 
are unlike any other kind of eruption. From rupia, the other form of 
bullar disease, it is to be distinguished by the smaller number of blebs 
in the former, by their greater flatness, and by the facts that these 
are followed by true ulcerations, and by thick and prominent scabs. 

Prognosis. — Acute pemphigus is rarely dangerous when it exists 
without complications. When, however, it is very extensive, and ac- 
companied with severe constitutional S}- mptomS; and particularly when 
it exists in connection with other diseases, or occurs in a child whose 
health has been broken down by unwholesome hygienic influences, it 
may assume a dangerous character^ and the prognosis should, therefore, 
always be guarded under such circumstances. 

Treatment. — Simple acute pemphigus requires, as a general rule, no 
other treatment than attention to diet, and regulation of the digestive 
function. When constipation is present, this should be overcome by 
means of simple enemata, or by the use of some mild laxative, as 
manna, spiced syrup of rhubarb, or very small doses of castor oil. If 
the discharges be too frequent, they should be restrained by the use of 
opium in doses proportioned to the age of the child. In young infants, 
it will often be found that the gastro-intestinal secretions are of an acid 
and irritating character. This condition may be treated with small 
doses of paregoric or laudanum, combined with lime or magnesia-water, 
or with soda. The diet must be managed according to the state of 
health of the child. For an infant, a good breast of milk is, of course, 
the best treatment in the world. For older children, the diet ought to 
be light and unirritating, but, at the same time, nourishing and strength- 
ening. 

The local treatment should consist, in the early stage, of an occa- 
sional warm bath. When the bullse have fully formed, they ought to be 
punctured, and the fluid gently pressed out, care being taken not to 
remove the cuticle, as this forms the best possible dressing for the in- 
flamed integument. When the bullae are followed by excoriations, 
these may be dressed with an ointment consisting of equal parts of 
Goulard's cerate and simple cerate, made a little soft by the addition 
of glycerin, or with carrot or elder-flower ointment, or with Turner's 
cerate. 

When the child shows signs of debility during the progress of the dis- 
ease, and also when the eruption tends to assume a chronic course, the 
treatment ought to be tonic and invigorating. It should consist in the 
use of a nutritious diet, and in the exhibition of tonics, as Huxham's 
tincture of bark, in small doses, quinia, arsenic, cod-liver oil, or in the 
use of wine-whe}^, or small quantities of brandy. 



926 RUPiA. 



AETICLE II. 



RUPIA. 



Definition; Yarieties. — Eiipia is an eruptive disease, character- 
ized in its early stage hj distinct, somewhat flattened bullae, of more or 
less considerable size, containing at first a serous, and then a purulent 
or blackish fluid : at a later period the disease exhibits very thick scabs, 
and still later, ulcerations. 

There are three varieties of this eruption : 7'upia simjjlex, rupia prom- 
inens^ and rupia escharotica. The latter variety was formerly described 
under the title of pemphigus infantilis and pemphigus gangrenosus, and 
is known in Ireland under the different names of white blisters, eating 
hive, and burnt holes. It is the most important variety of the disease 
in young children. 

Causes. — Eupia is most apt to occur in weakly, badly nourished, and 
scrofulous children, and seems to depend, therefore, upon that state of 
debility and exhaustion of the general health, which results from ex- 
posure to unfavorable hygienic conditions, which follows exhausting 
diseases, or which exists as a consequence of some hereditary taint. 

Symptoms. — Eupia simplex begins almost always on the inferior ex- 
tremities, or more rarely on the trunk or arms, without previous in- 
flammation, in the form of small, flattened bullae of about three or four 
lines in diameter. The bullae contain at first a serous and transparent 
fluid, which soon becomes thicker, and is converted into pus. At an 
early period they shrink and become wrinkled, their contained fluid 
hardens and is converted into rough, brownish scabs, which are alwaj^s 
thicker at the centre than on the edges, and which leave beneath, after 
their fall, superficial ulcerations. These ulcerations either soon cica- 
trize and disappear, or are covered by fresh scabs. After the fall of the 
final scabs, there yet remain, for some time longer, dark-brown or 
livid spots, which gradually fade and disappear. 

Rupia prominens exhibits the same general characters as the preceding 
variety, but with more marked and peculiar features. The eruption 
commences with a circumscribed inflammation of the skin, on which 
inflamed spot soon appears a bulla filled with yellowish serum, or some- 
times with a blackish fluid, which rapidly hardens into a brownish or 
blackish wrinkled crust. The crust is surrounded by an erythematous 
areola, formed by the extension of the cutaneous inflammation beyond 
the circumference of the scab. Upon this areola a fresh elevation of 
the cuticle, by purulent deposit, often takes place, which, by its desic- 
cation, adds to the size of the crust. This successive increase at the 
margin of the scab enlarges it in breadth, and, at the same time, raises 
the height of its centre, so as to give it a peculiar and characteristic 
appearance, and causes it to resemble very closely the shell of a limpet 
or oyster. The scabs thus formed usually adhere to the surface beneath 



RUPIA ESCHAROTICA. 927 

with much tenacity, and remain attached for a variable, and, as a gen- 
eral rule, considerable length of time. When at length they fall off, or 
are removed, there are left beneath ulcers of variable depth and extent, 
which are either covered by fresh crusts, or, as more frequently hap- 
pens, remain open, presenting a foul surface of a livid red color, with 
thickened edges. The ulcers are difScult to heal, and, after cicatriza- 
tion, leave livid or purplish stains, which often remain for months. 
The number of bullas is usually small, there being generally one at its 
height, and one or two about to appear, or on the decline. 

EupiA EscHAROTiCA. — This variety of rupia, formerly described as 
belonging to the class pemphigus, and then called pemphigus infantilis 
and gangrenosus, differs in some respects from the other varieties of 
rupia, and particularly in the absence of the thick and projecting 
crusts, which characterize rupia simplex and prominens. It occurs 
chiefly amongst cachectic children, appearing usually in the period be- 
tween birth and the first dentition. It is seated generally upon the 
neck, chest, abdomen, scrotum, or inferior extremities. 

The eruj)tion begins in the form of purplish or livid spots, raised 
slightly above the level of the skin. Upon these *spots the cuticle is 
soon elevated by a serous fluid, so as to form small bullae, which become 
rapidly larger, until thej" attain their full size. The bullae are smaller 
than in the other varieties of rupia; they are irregular in shape, flat- 
tened on the top, and are surrounded by purplish areolae in the early 
stage of the eruption; the fluid they contain becomes, at an early 
period, turbid and dark-colored, or almost black. The bullse soon 
wrinkle, burst, and leave ulcerated surfaces, which are painful, often 
covered with sloughs^ secreting a sanious and fetid pus, and difficult of 
cure. 

Soon after the formation of the ulcers, a fresh crop of bullae, forming 
a new eruption, often appears and passes through the same phases as 
the first, thus prolonging and extending the disease. This form of 
rupia is attended with much pain, with fever, sleeplessness, restlessness, 
and often ends fatally from the severe and continued irritation kept up 
by the disease. In cases ending favorably, the process of cicatrization 
is always slow and difficult. 

Diagnosis. — Eupia is likely to be confounded only with pemphigus 
and ecthyma. Pemphigus is to be distinguished from rupia b}^ the 
larger size and greater distension and prominence of its bullag; by the 
fact that the contained fluid of the latter is serous and transparent in 
pemphigus, instead of being turbid and sanguinolent, as in rupia; by 
the different character of the crusts, which, in pemphigus, are thin and 
lamellated, while in rupia they are thick and rugous; and, lastly, by 
the deep and unhealth3'-looking ulcerations that follow rupia. 

Ecthyma is unlike rupia in being a pustular disease from the first. 
Moreover, the pustules of ecthyma are surrounded by a highly inflamed 
areola, which is not the case in rupia, while the crusts in the former 
disease differ from those in the latter, in being smaller, harder, more 
irregular, and more adherent. 



928 RUPiA. 

Prognosis. — Eupia simplex and pvominens, though tedious and slow 
of cure, seldom prove fatal, while rupia escharotica is always danger- 
ous, and in very weakly children, especially when these are exposed to 
bad hygienic conditions, very generally ends unfavorably. 

Treatment. — The most important point in the treatment is to attend 
to the hygienic state of the patient. When the child is living in an un- 
healthy house, or a close and confined room, it should be removed, if 
possible, to a more salubrious position, or to a larger and well-ventilated 
room. The diet ought to be such as to invigorate the strength, and 
promote the nutrition of the body. For an infant who is fed upon 
artificial food, or who is suckling a nurse of doubtful health, the best 
remedy in the world is a fresh and full breast of milk. If a nurse 
cannot be procured, the diet must be most carefully regulated in ac- 
cordance with the principles already detailed in fall in the article on 
thrush, at page 331. While the diet is thus attended to, it is necessary 
to watch the state of the digestive organs, and if there be either con- 
stipation or diarrhoea, these must be overcome by suitable remedies. 
Tonics and stimulants are always advisable in this disease, and may 
consist either of brandy or wine, given alone, or in connection with 
Huxham's tincture of bark, extract of cinchona, small doses of quinia, 
iron, cod-liver oil, or any other remedy of this kind that may be pre- 
ferred. 

Eupia simplex and prominens are to be locally treated in the early 
stage by opening the bullae so soon as they form, and covering them 
with dry lint and a light bandage^ or with the water-dressing. The 
ulcerations that follow the bullse may be treated with Goulard's oint- 
ment, applied on pieces of fenestrated lint, and by washing occasion- 
ally with lime-water, or with weak solutions of alum, copper, zinc, or 
nitrate of silver. At a later period of the disease, when the ulcera- 
tions are covered with the characteristic thick crusts, these are first to 
be removed by means of poultices of bread and water, or flaxseed meal, 
and the surfaces beneath them treated with the applications recom- 
mended above. When the ulcerations are very obstinate and difficult 
to heal, they should be modified by occasional touchings with nitrate 
of silver, either pure or in strong solution, or with dilute nitric or 
muriatic acid. 

Billard recommends that the ulcerations should be dusted with pow- 
dered alum or cream of tartar, and Eayer also speaks very highly of 
the last-named application. 

Dr. Stokes found that the best treatment in epidemic rupia escharo- 
tica was an ointment of the scrophularia nodosa, made by stewing the 
small leaves of the plant in as small a quantity of unsalted butter as 
may be sufficient to prevent their scorching. The ointment is to be 
warmed until it becomes quite thin, and then applied by means of a 
brush, after which the surfaces are to be covered with lint smeared with 
the same ointment. The dressing is to be renewed every six hours. 



ECTHYMA. 929 

CHAPTEK lY. 

PUSTULES. 

ARTICLE I. 

ECTHYMA. 

Definition ; Synony3IS ; Varieties. — Ecthyma is an eruption char- 
acterized by prominent, rounded, and usually discrete pustules of con- 
siderable size, with hard and inflamed bases. The pustules are followed 
by thick, brownish crusts, which leave on their fall a reddish mark, or 
more rarel}^ a superficial ulcer or a true cicatrix. 

Ecthyma has been called also phlj'zacia. There are two varieties of 
the disease to which children are subject, ecthyma vulgare or acufiim, 
and ecthyma infantile. 

Causes. — The most frequent causes of ecthyma are the application 
of irritating substances to the skin, such as croton oil and tartar emetic 
ointment, and the presence of other eruptions upon the skin, particu- 
larly small-pox, measles, scarlet fever, herpes, or scabies. The causes 
just named give rise to the variety called ecthyma vulgare, which, it 
may be well to state in this place, is of an acute character, and has 
therefore been called by some writers ecthyma acutum. The other 
variety of the disease, ecthyma infantile, is a chronic affection, and 
occurs almost always in feeble, badly nourished, and cachectic chil- 
dren, and in those whose health has been injured and broken down by 
exhausting diseases, and particularly by disorders of the gastro-intesti- 
nal apparatus. 

Symptoms. — Ecthyma vulgare occurs most frequently on the extremi- 
ties and neck, and more rarely on the trunk of the body. It appears 
in the form of small, red, and circumscribed spots, projecting above the 
surface of the skin, hard to the touch, and accompanied by smarting 
and often severe pain, and by soreness on pressure. The centre of the 
spots is soon elevated into a pustule, filled with a purulent fluid. The 
size of the pustules varies, but is usually about that of half a pea. 
Each pustule is generally surrounded by a hard base of a bright red 
color, constituting an areola, while, in some instances, the whole of 
the red elevation is covered by the pustular formation. The pustule 
remains unchanged usually for three or four days, and more rarelj^ for 
a week, and is then converted, by the drj'ing up of the effused fluid, into 
a thinnish brown scab, which drops off after a few days, and leaves a 
congested purple spot that remains for some time longer. In other in- 
stances, the pustule breaks and leaves a small ulceration which termi- 
nates with a slight cicatrix. The eruption is commonly successive, and 
is seldom accompanied by any febrile reaction. 



930 ECTHYMA. 

Ecthyma infantile is much more frequently met with than the other 
variety of the disease, and occurs in a single, or oftener in successive 
eruptions, in feeble, badly nourished, and cachectic children. It ap- 
pears on the neck, shoulders, arms, and chest, and especially upon the 
lower extremities. It is often connected with some chronic disorder of 
the digestive or respiratory apparatus, and is developed during the 
state of debility and exhaustion to which children are reduced by those 
affections. 

The pustules of ecthyma infantile are of variable size, some being 
small, and others as large or larger than a sixpence. They are circu- 
lar in form, and surrounded by an areola of a red or purplish tint; the 
fluid which they contain is generally not very thick, and is of a dark 
and sanguinolent appearance; they terminate by the formation of a 
dark and adherent crust, by absorption of the contained fluid and a 
kind of desquamation, or by a bloody excoriation, or true ulceration, 
which are followed by a deep stain upon the skin or a true cicatrix. 

Diagnosis. — Ecthyma is more likely to be confounded with rupia, 
than with any other disease. The pustular character of ecthyma from 
th6 very beginning, will, however, almost always enable us to distin- 
guish it from the broad and distended bullae of rupia, filled with sero- 
purulent fluid; and the difference between the tw^o becomes still more 
marked, when we recollect the hard and inflamed bases on which the 
pustules of ecthyma rest, and the shapeless crusts and superficial exco- 
riations of that disease, instead of the projecting, rugous, and imbrica- 
ted scabs, and deep ulcerations of rupia. Ecthyma is not at all likely 
to be mistaken for the small and numerous pustules of impetigo, or the 
umbilicated ones of small-pox. 

Prognosis. — Ecthyma is never a dangerous disease in itself. If any 
danger accompany it, it arises rather from the enfeebled and disordered 
state of the general health under the influence of which it is produced, 
than from any injury caused by the eruption. The prognosis must de- 
pend, therefore, upon the state of the general health existing during 
the attack of the disease. 

Treatment. — In both varieties of ecthyma, attention to the general 
health of the patient constitutes the most important point in the treat- 
ment. In the acute form, mild laxatives, small doses of some altera- 
tive, as the hydrargyrum cum creta or sulphur, the use of a nutritious 
and wholesome, and especially of an unstimulating diet, and the local 
application of mucilaginous infusions, or of a mild and cooling oint- 
ment, as Goulard's cerate. Turner's cerate, or the carrot, cucumber, or 
elder-flower ointments, with occasional warm bathing, are all that the 
case demands. In the ecth3'ma infantile, the attention of the physician 
should be directed towards the restoration of the general health, which, 
as stated above, is always more or less deteriorated. As this deteriora- 
tion depends usually upon the exposure of the child to unwholesome 
bj'gienic influences, and a consequent unhealthy state of the digestive 
and nutritive functions, it is of primary importance that these should 
be early attended to. The patient ought to be placed in a healthy and 



STROPHULUS. 931 

well-ventilated apartment; the clothing must be regulated according 
to the age of the child, and the season of the year; and, what is most 
important of all, the diet ought to be such as is digestible, suitable to 
the age, and, at the same time^ nourishing and strengthening. The 
internal remedies must consist of tonics in all cases, and when the 
digestive j^o^er ^'^^^ general strength are reduced much below the 
normal standard, of stimulants. The best stimulant is old and pure 
brandy, either given mixed with water, three or four times a day, or 
combined wnth the food. The best tonics are, in most cases, some 
preparation of iron, and -the one we prefer is the iodide, given mixed 
with syrup of ginger, or, when the bowels are not too irritable, with 
small quantities of the compound syrup of sarsaparilla, or cod-liver oil. 
When, for any reason, iron is not given, quinia, or extract of cinchona, 
may be substituted. "While these remedies are being emploj^ed, or 
jDrior to their administration, the gastro-intestinal functions ought to 
be carefully regulated by the use of mild laxatives when the bowels 
are constipated, or by some kind of astringent when they are loose and 
disordered. 

The external or local treatment must consist in the use of mild de- 
mulcent applications, or of soothing or cooling ointments, during the 
pustular stage of the eruption. When unhealthy excoriations or ulcer- 
ations follow the pustules, these may be brought into good condition by 
the employment of weak solutions of nitrate of silver or sulphate of 
zinc, or of a very weak lotion of nitric or muriatic acid. 



I 



CHAPTER y. 

PAPULES. 

AETICLE I. 

STROPHULUS. 

This is a form of papular eruption which some writers regard as a 
variety of lichen, giving to it the name of lichen strophulus. It, how- 
ever, differs somewhat in its characters from the lichen of the adult, 
and, as it is peculiar to children, deserves a separate consideration. 

Strophulus is a disease affecting chiefly infants at the breast, charac- 
terized by a more or less extensive, and sometimes a general eruption 
of papules, which are whiter or redder than the surrounding skin, and 
are accompanied by more or less irritation and itching. 

Its causes are various disturbances of the digestive apparatus in 
very young infants, and in older ones the effort of the first dentition. 

Varieties and Symptoms. — The strophulus intertiiictus, or red gum, 



932 STROPHULUS. 

consists of an eruption of prominent pimples of a vivid red color, scat- 
tered here and there over different parts or the whole of the body, and 
intermingled with small erythematous patches. The eruption remains 
upon the skin for some time, the papules disappearing and reappearing 
in successive crops, for a week or two, or more, until they terminate 
by desquamation. It is most common upon the cheeks, backs of the 
hands, and forearms. 

In strophulus conferfus, the papules are much smaller, more closel}^ 
aggregated, much more numerous, and more confluent, than in the first 
variety, and they constitute a more severe eruption. It may be distrib- 
uted over the whole surface, but is more commonly limited to a single 
spot; or to several regions, as the face, breast, or arms. The eruption 
is less vivid, but more lasting than that of the strophulus intertinctus, 
and usuall}^ reaches its height in twelve or fourteen days, and then 
subsides. 

In strophulus volaticus, the papules, which are of a vivid color, are 
disposed in small, not very numerous, circular groups, scattered over 
the surface of the body, but met with most frequently on the cheeks 
and arms. 

The two remaining varieties, strophulus albidus or white giwi, and 
strophulus candidus, are both characterized by whitish instead of red 
papules. In the former, the papules are white, minute in size, and sur- 
rounded each by an areola of a faint red color; they appear usually on 
the face, neck, and breast, and continue for some length of time. In 
the latter, the papules are much larger, broader, more hard and tense, 
and are unaccompanied by any redness. They last usually about a 
week. This eruption is most common during dentition. 

Diagnosis. — There is no difficult}^ in distinguishing strophulus, as it 
is the only papular eruption to which infants are subject. The absence 
of general symptoms and the extreme mildness of the disease are 
amongst its chief characters. It must be remembered that we only 
regard such papular eruptions as are unassociated with exudation or 
eczematous patches elsewhere on the surface as true instances of stroph- 
ulus, since papules in all respects resembling those of this disease are 
to be frequently observed in cases of eczema papulosum. 

Prognosis. — The eruption is never attended with any danger. If 
severe symptoms happen to coincide with it, they must depend on some 
other causes than the cutaneous affection. 

Treatment. — As a general rule, strophulus needs no treatment what- 
ever. In infants within the month, the irritation of the skin^ if it be 
such as to disturb the comfort of the child, may be allayed by the use 
of the tepid bath, and by dusting with some mild powder, or by anoint- 
ing with cold cream, glycerin and cold cream, simple cerate, or cocoa- 
butter. When any marked disturbance of the digestive apparatus is 
present, this should be attended to by the administration of mild laxa- 
tives, and of tonics, with some preparation of iron, as the tartrate or 
superphosphate. 

In older children, in whom the disease appears to be associated with 



LICHEN. 933 

dentition, the local means spoken of above may be employed, while, at 
the same time, the gams should be lanced, if necessary, and any gastro- 
intestinal disturbance removed by ai:)propriate treatment. 



AETICLE II. 



LICHEN. 



, 



In children the lichenoid eruption takes so constantly the form of 
strophulus, that we deem it unnecessary to give a separate description 
of the former disease, with the exception of one of its varieties, the 
lichen tropicus. No doubt cases of lichen simplex do occasionally occur 
in children as they approach the age of adolescence, but since the dis- 
ease resembles so closely in its characters, and requires the same treat- 
ment as strophulus, what has been said in regard to that disease will 
perfectly well apply also to lichen. Of lichen agrius, a not uncommon 
and severe form of the eruption in adults, we have never seen an ex- 
ample in a child. 

Lichen Tropicus, or Prickly Heat. — This is a form of lichen sim- 
plex which occurs principally in hot climates, and during the hot sum- 
mer season of the more southern temperate climates. It is a very 
common eruption at all ages of childhood, from early infancy upwards, 
in this city, and in most of our Middle and Southern States, and is com- 
monly known by the name of prickly heat. 

The chief cause of lichen tropicus is apparently the action upon the 
cutaneous surface of a high temperature, aided, no doubt, by the dis- 
turbances of the digestive function so apt to occur under the influence 
of that condition of the atmosphere. Yery warm clothing, and par- 
ticularly the presence upon the skin of thick rough flannels, is apt to 
develop the eruption. 

Symptoms. — The eruption of prickly heat consists of numerous small 
papules, few of them being larger than a pin's head, scattered more or 
less thickly over the affected surface. The pimples are of a red color, 
which is more or less bright in tint, according to the extent and inten- 
sity of the eruption. The skin between the papules retains its natural 
appearance when the eruption is but slight or moderate; but when 
this is copious and severe, it assumes a faint reddish appearance, owing 
no doubt to the activity of the circulation in the part. 

The eruption is most abundant on the parts covered by the dress, or 
rubbed by the edges of the dress, particularly about the neck, upper 
part of the chest, and on the arms and legs. We have sometimes seen 
it covering the greater part of the body. It is always attended with 
more or less itching, burning, and pricking, which, in older children, 
cause much fretfulness and scratching, and, in those who are younger, 



934 PRURIGO. 

restlessness, worrying, and more or less disturbance of the sleep. The 
disorder usually remains stationary for several days, and then disap- 
pears gradually without desquamation or other change in the skin; or, 
it subsides and increases, or disappears and returns, with the rising and 
falling of the temperature, or without any very evident cause, until at 
last it ceases, not to appear again. When the eruption lasts many days, 
it is almost always accompanied by a slight scaly desquamation of the 
tops of the pimples. 

The diagnosis of this form of eruption is never difficult. Its occur- 
rence during hot weather, the character of the papules, their minute- 
ness and abundance, and the entire absence of constitutional disturb- 
ance, will always render it easy of recognition. 

Treatment. — Lichen tropicus is usually regarded as a salutary erup- 
tion, and as therefore not to be interfered with by treatment likely to 
repel it. In fact, it never needs any treatment, except when very abun- 
dant, and when it annoys the child by the heat and itching it occasions. 
Under these circumstances, the skin should be dusted with rj^e-meal, 
or anointed two or three times a day with some mild ointment, as, for 
instance, one consisting of glycerin and cold cream or lard, or the ben- 
zoated zinc ointment; or, the child may be bathed once or twice a day 
in warm water containing bran, slippery-elm, or some other mucilagi- 
nous substance. 



AETICLE III. 

PRURIGO. 

Definition; Frequency. — Prurigo is characterized by an eruption, 
more or less extensive, of isolated papules, which, larger than those of 
strophulus, unattended with any change in the color of the skin, and 
developed usually on the extensor surfaces of the limbs, give rise to the 
most violent and distressing itching, a symptom which constitutes one 
of the most marked features of the disease. Wilson includes it among 
the nervous affections of the skin, and attributes it usually to nervous 
debility, with an impaired state of the nutrition and innervation of the 
skin. 

Prurigo is a rare disease in this city amongst the children of the 
middle and upper classes, since we have seldom met with it. In Europe, 
it is described as occurring in the children of the poor, though it is 
much less common than the eruptive diseases already treated of 
Doubtless it occurs in this country also, but we have not found any 
original account of it in the works of American writers. 

Causes. — The only well-ascertained causes of the disease are the un- 
favorable hygienic conditions which exist amongst the destitute classes 
of society, — damp and ill-ventilated dwellings, unwholesome food, es- 
pecially the use of salted meats and fish, and want of cleanliness as to 
person and clothes. 



SYMPTOMS — DIAGNOSIS — PEOGNOSIS — TREATMENT. 935 

Symptoms. — The papules of prurigo are small, but slightly prominent, 
and attended with moderate itching, constituting the prurigo mitis ; or 
they are larger, more projecting, and attended with the most violent 
pruritus, forming the prurigo formicans. The papules are usually of the 
color of the skin, except when they have been torn by the nails, and 
are generally seated upon the outer surfaces of the limbs, and the upper 
part of the trunk. 

When the itching is severe, the tearing of the papules by the nails 
causes the escape of a small drop of blood from the tops of many of 
them. The blood dries and forms so many small black crusts crown- 
ing the summits of the papules, a peculiarity which constitutes one of 
the most distinctive features of the disease. The papules terminate by 
absorption or by a slight desquamation. 

The duration of the eruption is very uncertain. In acute eases, when 
properly treated, it may end in a few weeks, though it often, and indeed 
more generally, lasts for several months. 

Diagnosis. — The only diseases with which prurigo is likel}^ to be 
confounded are strophulus or lichen. It may be distinguished, how- 
ever, generally with ease, by the facts that the papules of prurigo are 
larger, less numerous, and more extended, than those of strophulus or 
lichen ; that in the latter diseases the papules are never crowned by 
the small black crusts of prurigo, and they are never attended with the 
same violent itching as the former. 

Prognosis. — Prurigo is never perhaps a dangerous disease, though 
usually a very troublesome one from the severe irritation which attends 
it, from its not unfrequently obstinate resistance to treatment, and its 
disposition to relapse. 

Treatment. — The internal treatment of prurigo in children should 
consist in the use of sulphur, given alone or in combination with mag- 
nesia, of demulcent drinks, of mild laxatives when there is constipation, 
and of such remedies as may be rendered necessary by any disordej'ed 
state of the digestive function. The diet must be carefully regulated. 
It ought to be nourishing and sustaining, but at the same time light 
and easy of digestion. 

In addition to the internal treatment, simple warm-water baths, or 
emollient baths of flaxseed, bran, slippery-elm, or marsh-mallow, should 
be made use of in the early stage of the disorder. At a later period, 
alkaline baths, containing from three to eight ounces of carbonate of 
potash to each bath, according to the age, are recommended by Caze- 
nave and Schedel. To allay the cutaneous irritation, mild ointments 
are often found useful. Billard employed with success, in a child six 
months old, inunctions with the oil of sweet almonds. Soaps or lo- 
tions, containing juniper tar or carbolic acid, are excellent anti-prurigi- 
nous applications; and relief will frequently be obtained from the 
application of a dilute solution of chlorinated soda. When the case 
is obstinate, resisting emollient and alkaline baths, sulphurous baths 
must be made use of. 



936 SQUA 



CHAPTER VI. 

SQUAMA. 

The various forms of scaly disease, psoriasis, pityriasis, and ichthyo- 
sis, are so much more rare in children, and therefore so much less im- 
portant practically, than the various eruptions we have thus far con- 
sidered, that we deem it unnecessary, in a work limited in extent like 
this, to attempt a detailed account of them. We shall make merely a 
few observations on each, referring the reader, should he desire further 
information, to the special treatises upon diseases of the skin. 

Psoriasis is, in our experience, a very rare disease in children, though 
we have met with a few cases of it. It is met with in two forms, the 
psoriasis diffusa and guttata, of which the former is said to be the more 
frequent. 

Psoriasis diffusa appears in the form of patches of rather large, but 
very variable size, of irregular shape, and covered with thin scales of 
dried epidermis, which are constantly falling off and being renewed. 
When the scales are removed, the surface of the eruptive patch is seen 
to be of a dull red color, somewhat rough, and raised above the sur- 
rounding skin. In severe eases, as the disease occasionally occurs in 
young children, the skin presents numerous chaps and fissures, and is 
often excoriated more or less by the dress, or by the neighboring sur- 
faces. From the excoriations is sometimes poured out an unhealthy 
secretion, which hardens and forms scabs. 

Psoriasis guttata appears in small, reddish, and rounded elevations, 
more elevated at the centre than the circumference, and of different 
sizes; from that of the head of a pin, as mentioned by Billard, to that 
of a large pea, as seen by ourselves, and which become covered very 
soon after their appearance with fine, minute and whitish scales. 

A third variety, psoriasis inveterata, a severe, obstinate, and invete- 
rate disease, as met with in adults, is very rare, if not unknown, in 
children. 

Treatment. — In recent cases, psoriasis is to be treated with simple 
warm-water or emollient baths, and with mild liniments or ointments, 
such as oil of sweet almonds, glycerin alone, or glycerin mixed with 
cold cream or simple cerate. In more chronic cases, the local treatment 
is the only one which promises any certain success. The particular 
mode of local treatment which we have found most successful is that 
recommended by Hebra, a short account of which w^ill be found in our 
remarks on the treatment of chronic eczema. 

The carbolic acid soap, dilute citrine ointment, or weak solutions of 
caustic potash when there is much infiltration of the skin, are all service- 
able applications in the chronic form of the disease. 

In all cases the digestive function must be carefully attended to, any 
disorder that it may present being removed as rapidly and effectually 
as i^ossible by the proper remedies. 



PAKASITIC SKIN DISEASES. 937 

In cases Tvhere the eruption persists despite the use of local applica- 
tions and attention to the digestive functions, the child should be placed 
upon the use of the ferro-arsenical mixture. 

Pityriasis is a slight scaly disease, which may attack the head only, 
or extend to other parts of the body. In children, however, it is 
generally confined to the scalp, and may be recognized by the existence 
on the part of innumerable small, thin, whitish, furfuraceous scales, 
which form a thin or thicker covering for the scalp, in proportion to 
the amount of care bestowed on the cleansing of the head. The scales 
of epidermis are easily rubbed off, and the surface beneath is rarely 
found to present even the slightest inflammation. 

It is a disorder of minor importance, and seldom requires other treat- 
ment than some mild lotion or ointment, and strict cleanliness. When, 
however, it persists, the child should be placed upon the use of the 
ferro-arsenical mixture internally, and applications of dilute citrine oint- 
ment should be made to the patches of eruption. 

Ichthyosis is an eruptive disease in which there appears on various 
parts, and usually over the larger portion, of the skin, epidermic patches 
or squamae, that are hard and dry, and of more or less considerable size. 
The patches are generallj^ of a dirty gray or earthy color; they exfoli- 
ate, and leave the skin beneath a little thickened and roughened, but 
never inflamed. The disease is unattended with either heat, pain, or 
itching. It is ordinarily congenital, lasts many years, and, according 
to MM. Cazenave and Schedel, is incurable. 

Billard recommends, however, in the ichthyosis of new-born children, 
the use of warm and emollient baths, frictions, with oil of sweet almonds 
or olive-oil, acidulated drinks, and perfect cleanliness. 



CHAPTEE yil. 

DISEASES OF THE SKIN NOT CLASSIFIED AMONGST THE PRECEDING. 

SECTION I. 

PARASITIC SKIN DISEASES. 

General Eemarks. — The diseases now regarded by man}^ authorities 
as due to the presence of a vegetable parasite upon the skin are as fol- 
lows : 



1. Tinea Favosa or Favus Parasite : Achorion Scha^nleinii. 

„ _. ^. f Tinea Tonsurans (Rinsfworm of scalp), \ 

2. Tinea Trico- m- ri- • * /x>- r -u ^ i I -n -i. m • 1 . 

-I linea Circinata (Ringworm of body), V Parasite: Tricopliyton. 

P ^ ' ( Tinea Sycosis (Ringworm of beard), J 

3. Tinea Versicolor (Chloasma, Wilson), . . . . Parasite: Microsporon Furfur. 

4. Tinea Decalvans (Alopecia Areata), " Microsporon Audouini. 



938 PARASITIC SKIN DISEASES. 

There are several questions, however, in regard to these affections 
upon which doubts still exist, and which are of so much importance as 
to demand a brief examination. 

In the first place, it can scarcelj^be doubted by any one fiimiliar with 
the use of the microscope, and who has taken the trouble to examine 
the subject, that parasitic fungi are found with remarkable constancy 
in the eruptions of these diseases. The opinion advanced by Wilson 
{Br. and For. Med.-Chir. Bev., 1864, and Diseases of the Skin, 7th Amer. 
ed., p. 614), that the structures found in these cases, are due to a peculiar 
"granular" degeneration of the normal elements of the part, owing to 
which they lose their power of developing into healthy epithelial struc- 
tures, but retain their power of proliferation, appears to us oi:>posed to 
all sound reason and accurate observation. 

In addition, however, to the evidence furnished by the chemical and 
microscopical examination of the growths in question, their fungous 
nature is shown by the facts that they can be cultivated after removal 
from the bodj'-, and that the diseases with which they are associated are 
contagious and can be communicated by inoculation to healthy persons, 
or even to some of the lower animals. 

In searching for these growths, the scrapings from the surface of the 
diseased spot, or the hairs which traverse it, may be taken for examin- 
ation ; but before subjecting them to microscopic study, they should be 
treated with dilute acetic acid to render them more translucent, and 
subsequently with a little sulphuric ether to remove the fatty granules 
which often obscure the fungus. 

The structures which the fungi affect are the hairs with their follicles, 
and the epidermis. 

The special alterations which the hairs undergo will be detailed 
under the head of the different diseases; the fungus gains entrance to 
the follicle, penetrates the bulb of the hair, insinuates itself between 
its longitudinal fibres, thus splitting it up and rendering it brittle. In 
the epidermis the fungus is said at first usually to appear beneath the 
superficial layer, until, by its development, it causes such irritation as 
leads to the exfoliation of this layer, when it reaches the surface and 
then multiplies rapidly. 

The objection which has been based upon this fact, that the growth 
cannot be a parasitic one, does not seem to us of much force, since it 
is easy to account for the introduction of such extremely minute bodies 
as the spores of these fungi beneath the superficial layer of the cuticle. 

Admitting then the presence of these parasitic growths, a more in- 
teresting question arises in regard to the relation which exists between 
them and the diseases with which they are associated; whether, that 
is, they are essential to, and actually the causes of the respective dis- 
eases, or are merely accidental, and are present only because they find 
a suitable nidus for development in the diseased skin. Opinions are at 
variance upon this question, but there are at least two considerations 
which render it probable that the fungi are essential rather than acci- 
dental productions. The first of these is, that they are present in the 



FUNGUS OF FAVUS. • 939 

early stages of the disease, before any considerable inflammatory 
chano-e bas occurred, and that in proportion as suppuration ensues they 
diminish in abundance. And, secondly, tbat, as already stated, they 
are capable of transmission to perfectly healthy persons by inoculation. 

There can, however, be no doubt that the development of the fungus, 
under ordinary circumstances, is greatly favored by the constitutional 
condition of the patient and the state of the cutaneous surface. Thus 
it is especially in children of a delicate or strumous constitution, that 
these various diseases are most frequently met with; and when, in 
addition, personal filthiness with inattention to properly combing and 
cleansing the hair, and changing the clothing, are combined, the spores 
find the most favorable conditions possible for their rapid development. 

There remains the further question, upon which authorities are still 
divided, whether there are various fungi concerned in the production 
of these diseases, or whether the apparentl}^ different species are merely 
different stages of a single fungus. For the sake of greater ease of 
reference and comparison, we will here give a brief description of their 
characteristic appearances. 

Fungus of Favus. — In the earliest stage of development of the favus 
crust, it is still covered by the superficial layer of epidermis ; but later, 
when this is ruptured, it still presents an envelope of a sulphur-yellow 
color, which on microscopic examination shows a homogeneous or finely 
granular substance. The interior, of a pale white color, is the true 
favus matter, and consists of the sporules, thalli, and mycelia of a 
fungus named the achorion Schoenleinii, in honor of Schoenlein, who 
first fully described it. 

The sporules are of a rounded, or more frequently of an oval form, 
and have well-marked edges, and a homogeneous and slightly opales- 
cent interior. Their average diameter is about Wooth of an inch. 
Many of these sporules are seen to be grouped together, while some 
are more elongated and present a contraction in the middle; others are 
nearly triangular in form, with rounded angles; others, yet more elon- 
gated, are marked with several contortions. Some sporules, completely 
formed, seem to have a double envelopment membrane, and others 
present in their interiors something like a nucleus. 

There are also present numerous diaphragmated tubes, formed by 
the development and confluence of the sporules, which are either simple 
or present ramifying branches. These tubes vary in diameter from 
4oVoth to Tsiooth of an inch, and are either empty or have granular 
contents. Amongst the sporules and mycelia, especially towards the 
circumference of the cups, ra^j be seen a considerable number of molec- 
ular granules, which are probably imperfectly developed sporules. 

The next parasite, the t?icophyton, is that which, according to McCall 
Anderson, and some other dermatologists, produces tinea tonsurans, 
tinea circinata, and tinea sycosis. 

The microscopic characteristics of this parasite, as first described by 
Malmsten, in 1845, and since confirmed by numerous observers, are very 
numerous rounded or oval sporules, about -oVoth of an inch in diameter^ 



940 PARASITIC SKIN DISEASES. 

which are isolated or united together into chains, and a comparatively 
small number of m3'celial threads. 

Again, the parasite, which by many observers is believed to cause 
tinea versicolor, is the microsporon furfur^ discovered by Eichstadt, in 
1846. This fungus presents numerous rounded spores, and long tubes. 
The spores are about -go^ou^^ m(j\\ in diameter, and are frequently col- 
lected together in large clusters, like bunches of grapes (Anderson). 
Some of the tubes observed are simple, and others jointed. 

In regard to the parasitic nature of alopecia areata, there is great 
doubt, and even so warm a supporter of the fungous origin of the other 
diseases we have mentioned, as Dr. Anderson, does not allow it. 

Numerous observations have been made which go to show the exist- 
ence of a very wide range of variation as regards form in these fungi; 
and have led some observers to assert not only the identity of these 
particular forms, but indeed to refer all varieties of epiphytic fungi to 
some one central type. 

The evidence upon which this view rests, mainly drawn from the 
results obtained from germination of the various fungi, and from the 
study of their transitional forms, cannot at present be considered con- 
clusive; and further investigation of the question is demanded. 

It is, however, thought by some high authorities, that no doubt can 
be entertained in regard to the identity at least of the parasites which 
produce the various forms of tinea, including the achorion of favus, the 
microsporon furfur of tinea versicolor, and the tricophyton of the vari- 
ous varieties of ringworm. The most complete exposition of the argu- 
ments upon which this view is based, will be found in Dr. Tilbury 
Fox's admirable treatise on skin diseases of parasitic origin (London, 
1863). 

On the other hand, some eminent dermatologists believe that the 
fungi which produce these diseases, are essentially distinct. The argu- 
ments upon which they base this opinion may be briefly expressed as 
follows, in the language of Dr. Anderson {Joe. cit., p. 170). 

That in all cases of successful inoculation with the achorion, trico- 
phyton, and microsporon furfur, the same parasitic disease has been 
produced as that from which the parasite was taken. That of the in- 
numerable cases occurring in the human subject, illustrative of the con- 
tagious nature of favus, tinea tonsurans, and tinea versicolor, there is 
no authentic case in which one of these diseases gave rise to one of the 
others. 

That the difference in the appearance of the eruptions, when fully 
developed, is so very striking as to lead to the belief that they are pro- 
duced by separate parasites. 

That there is no authentic record of the transition of one of these 
diseases into one of the others. 

That the microscopic differences between the three fungi are in 
many cases sufficient to base a correct diagnosis upon. 

That of the numerous instances on record of the transmission of 
tinea favosa, and tinea tricophytina, from the lower animals by con- 



FAVUS. 941 

tagion or inoculation, favus has always given rise to favus, and tinea 
tricophytina to tinea tricophytina. 

We regard then the parasitic nature of these affections as undoubted, 
but more extended observation is necessary before the relations of their 
respective fungi can be determined. 



ARTICLE I. 



FAVUS. 



Favus is a parasitic disease of the scalp, long confounded by differ- 
ent writers with other and very dissimilar affections of that part. In 
consequence of this confusion it has received a great variety of names, 
of which the most generally known are porrigo and tinea. In adopting 
the above title, we follow the example of Erasmus Wilson and other 
recent authorities, amongst the English, and of MM.Rilliet and Barthez, 
Gibert and Rayer, amongst the French. 

Definition; Synonyms; Varieties; Frequency. — Favus is a specific 
contagious eruption of the scalp, characterized by inflammation of the 
hair-follicles dependent upon the presence of a peculiar fungus, the 
achorion Schoenleinii. It is distinguished at first by small yellow pus- 
tules, countersunk in the skin; these are soon converted into yellow 
cuplike crusts, which adhere often for a very long period. It usually 
causes permanent loss of hair at the affected part. 

The disease is described by most of the former English writers under 
the title of porrigo, but as several other eruptions have been included 
under the same name, w^e think it best to follow the example of Mi*. E. 
Wilson, and call it favus. By MM. Biett and Cazenave it is designated, 
after Willan, porrigo favosa and porrigo scutulata. MM. Rayer and 
Gibert, as above mentioned, give it the name of favus. 

There are two varieties of favus, the favus dispersus, the porrigo fa- 
vosa of most writers, and the favus confertus, the porrigo scutulata of 
many observers. 

The disease is much less frequent than eczema of the scalp, but is 
nevertheless constantly met with amongst the crowded populations of 
Europe. In this country it is more rare, and amongst the middle and 
upper classes, at least of this city, is almost unknown, since we have 
never met with a case of it in our own private practice, though we have 
occasionally seen it in the hospitals here. 

Causes. — The only well-ascertained exciting cause of favus is gener- 
ally thought to be contagion, a quality of the disease acknowledged by 
most observers, though denied by Mr, E. Wilson, who considers its 
cause a debility of nutritive vitality, allied with struma. It may be 
propagated by direct contact of the diseased with a healthy skin, or by 



942 FAA^US. 

means of combs, brushes, or other articles of the toilet; and it is also 
l^robable that the spores may be carried by the atmosphere so as to 
communicate it by infection. It has been frequently propagated by 
direct inoculation, — by Eemak, Bennett, Hebra, Bazin, Gruby, Kobner, 
&c. 

Favus is also said to be met with in the lower animals, and especi- 
ally amongst mice and cats; and cases are on record which render it 
highl}^ probable that it may be communicated from them to the human 
subject. 

It occurs at all seasons, attacks either sex indifferently, and is met 
with at all ages, but is especially frequent in children and young peo- 
2)le, and, indeed, when met with in adults, is usually found to have 
commenced in early life, and to have persisted for years. Certain con- 
ditions act as predisposing causes in its production, and may alone, 
perhaps, give rise to its development. These conditions are unhealthy 
hygienic influences, as unwholesome and insufficient food, poverty, 
tilth, and the living in low, damp, and ill-ventilated dwellings. It is 
met with most frequently in persons of feeble, lymphatic, and especi- 
ally in those of scrofulous constitution, though, be it remarked, it 
occurs also in persons of strong and vigorous health. 

Among those who believe in its truly parasitic nature, there are 
some, as Devergie, who believe that it may be spontaneous!}^ generated, 
the parasite oi'iginating in the body of the affected person. One of the 
facts upon which this theory is based is the asserted occasional cure of 
the disease by internal remedies, but we believe that these can only 
relieve it by fortifying the s^'stem, and so removing the conditions 
which favored the development of the parasite. 

Symptoms. — Favus Dispersus, or Porrigo Favosa. — This variety 
begins with very small pustules of a peculiar straw-yellow color, w^hich 
exhibit from the first the special character of not being raised at all 
above the level of the skin. Directly after their formation, the yellow- 
ish matter which they contain begins to concrete, and there can be 
perceived from this early period a central depression in the crusts, 
which becomes more marked as these augment in size, so that at the 
end of five or six daj'S it is perfectly evident. Each pustule, and of 
course each crust is, as a general rule, traversed by a hair. The favous 
crust is a very remarkable feature of the disease, and is in itself a 
pathognomonic symptom. As it increases in size, which it does gradu- 
ally until it reaches in some instances a diameter of half an inch, the 
central depression above spoken of becomes more and more distinct, 
and the crust assumes, from this circumstance, the shape of a cup with 
an inverted edge. This cuplike form, the peculiar straw-yellow color, 
and the fact that each crust is usually pierced by a hair, are the distin- 
guishing characters of the disease. 

The pustules are usually isolated at first, though they may be ar- 
ranged in groups of irregular size. When numerous, the crusts, by 
their gradual enlargement, touch at their edges, and blend into larger 
or smaller patches of irregular shape, but still presenting many little 



SYMPTOMS. 943 

depressions corresponding to the first-formed pustules. In rare cases, 
the disease is so extensive as to form a kind of mask covering the whole 
scalp. 

When the disease is not interfered with by treatment, the crusts re- 
main adherent for a long time, — for months or even years ; the}' become 
also paler in color than they were at first, and so dry and pulverulent, 
as to break very readily when rubbed or touched. They become, more- 
over, thicker and more massive, and lose their first regular cuplike 
form, from the disappearance of their depressions, and from the irregu- 
lar and uneven shape given to their edges and surfaces, by the break- 
ing which they undergo. When the case runs on in this way, the head 
exhales a most unpleasant odor, which has been compared to that of 
mice or the urine of a cat; McCall Anderson has, however, noticed a 
very similar odor in cases of eczema impctiginoides of the scalp. In 
some instances, where the disease is grosslj" neglected amongst the very 
poor, pediculi form in abundance amidst the crusts, and add to the dis- 
gusting appearance of the disorder. 

When the crusts have been removed by any means, the surface of 
the scalp is seen to be red, moist, and to present slight erosions or even 
ulcerations. The crusts are reproduced only by the eruption of new 
pustules. 

An invariable and unfortunate sequel to the favous disease is a more 
or less extensive loss of the hair. The hairs become loose from a very 
early period of the disease, and can be pulled out with great ease. As 
the case goes on they fall out, and the scalp is left smooth, shining, un- 
even, and deprived of hair. On these spots the hair seldom grows 
again, and if it does, it comes out thin, wooll}^, and with every appear- 
ance of weakness and unhealthfulness. 

Though the usual and favorite seatof favus is the scalp, it is met with 
occasionally on the forehead, temples, chin, and eyebrows, and, in still 
rarer instances, on the shoulders, elbows, forearms^ on the upper and 
outer parts of the legs and thighs, on the scrotum, and even on the 
nails. Even in such cases, however, it has generally existed first on 
the scalp, and extended thence to the other j)arts, though it may some- 
times begin upon the trunk or limbs in consequence of a direct applica- 
tion to them of the contagious element. 

Favus Confertus, or Porrigo Scutulata. — In this variety of favus 
the pustules are arranged so as to form circles or rings upon the fore- 
head or scalp, instead of being dispersed irregularly over the scalp, as 
in the preceding variety. The disease begins with red, circular patches, 
attended with a good deal of itching, uj^on which, after a short time, 
appear small yellow pustules, that seem to be sunken in the skin. The 
pustules are more numerous on the circumference than at the centre of 
the red patch or disk; or the latter increases in size by the extension 
of the disease to the follicles just beyond its outer edge. The pustules 
are exactly like those of favus dispersus, except that their yellow color 
is of a lighter tint. They desiccate very rapidlj', and form crusts which 
are very thin at first, never very thick, and of an irregular shape. 



944 FAVus. 

Wlicn the disks are very numerous, either originally, or by propaga- 
tion of the disease from part to part, they meet at their borders, blend 
together, and give to the scalp the appearance of an extensive and 
irregular crust, presenting at its circumference curved lines, marking 
the segments of circles of which the whole is composed. The crust 
has sometimes covered the whole scalp, excepting merely a small border 
at its circumference, where may still exist some scanty remains of the 
hair. 

When the crusts are removed, the surface beneath is found to be red 
and tumid, according to Wilson, and to present numerous yellow points. 
Cazenave and Schedel state that when the crusts fall, they leave ex- 
posed a large, uneven, furfuraceous patch, upon which new favous pus- 
tules do not appear often for a long time. The hair is in great meas- 
ure destroyed over the diseased surfaces, though not so completely, it 
is said, as in the other variety. 

Favus is not, in either variety, attended with constitutional symp- 
toms. The only marked local symptom complained of is the itching, 
which is always greatly aggravated by want of cleanliness. 

JS'ature of Favus. — We have already, in our general remarks intro- 
ductory to this class of skin diseases, given the arguments which prove 
their parasitic nature. 

Mr. E. Wilson, alone among dermatologists of note, persists in regard- 
ing favus and the others, as due to mere alterations in the nutrition of 
the skin dependent upon constitutional nutritive debility; and he refers 
the characteristic fungous elements revealed by microscopic examina- 
tion, merely to a peculiar granular degeneration of the epithelial ele- 
ments. 

We refer the reader, for a more full discussion of this question, to 
the works already quoted, merely adding here that, in our opinion, the 
results of microscopic examination, the results of inoculation of the 
parasite in man, as well as in the lower animals and plants, the undoubt- 
edly contagious nature of the disease, and finally the astonishing and 
never-failing success of the local treatment when properly carried out, 
conclusively show its parasitic nature. The reader is also referred to 
the remarks introductory to this chapter for a full description of the 
parasite, the achorion Schoenleinii, which is the essential cause offiivus; 
as well as for the differences which distinguish it from the parasites 
which are found in the various forms of tinea. 

Diagnosis. — The diagnosis of favus rarely presents any difficulties. 
The peculiar pustules which exist at first — small, yellow, on a level with 
or below the surface of the scalp, and the crusts which so soon follow 
these, saffron-yellow in color, dry, and cup-shaped, will mark a case of 
faviis dispcrsus from every other disease. In favus confertus the same 
characters exist, but the crusts and pustules are arranged on circular 
erj^thematous disks, instead of being isolated or dispersed as in favus 
disi)ersus. 

From impetigo of the scalp, which is the only disease with which it 
is at all probable that it would be confounded, it may readily be dis- 



PROGNOSIS — TREATMENT. 945 

tingnished by an examiDation of the primary characters of the two 
disorders. This primary character can always be found by searching 
at tlie outer edges of the diseased surface. In favus the pustule is 
small, depressed, and contains very little fluid, while in impetigo it is 
large, globular, and projecting. The crusts are very different: in the 
former dry, as though dusted with sulphur, cup-shaped, depressed, and 
usually traversed by a hair; in the latter, rugous, irregular in shape, 
not cupped, resting above the skin, and generally somewhat moist and 
soft. The microscopic examination of the hair or crusts in favus also 
shows the presence of the achorion Schoenleinii, which is never met with 
in impetigo. Lastly, the alopecia which so constantly results from 
favus, does not occur in impetigo. 

Prognosis. — Favus is a serious disease because of its usuall}^ long du- 
ration, the difficulty often experienced in effecting its cure, and because 
of the loss of hair which it occasions. 

Treatment. — The treatment of favus should be both general and 
local, for though some writers, and particularly Cazenave and Schedel, 
state that it must be altogether external, and that in spite of numer- 
ous trials they do not feel authorized to propose any internal means 
(^Malad. de la Peau, 4eme ed., p. 326) ; others, as Wilson, Bennett, and 
Neligan, recommend constitutional remedies as of very great impor- 
tance in assisting the cure. 

The general treatment must be such as may seem called for by the 
state of health of the individual patient. When, as so often happens, 
the disease occurs in a scrofulous person, cod-liver oil, iodide of potas- 
sium, nourishing food, air, and exercise, are of the utmost importance. 
When the health of the patient is feeble and broken from the want of 
wholesome and abundant food, from insufficient clothing, or from resi- 
dence in a vitiated, close, and confined air, the removal of these condi- 
tions, which undoubtedly act as predisposing causes in the production 
of the disease, cannot but aid in its cure. Dr. Neligan (^Dublin Quart. 
Journ. of Med. Sci., vol. vi, p. 56) recommends very highly the use of 
the iodide of arsenic as a constitutional remedy. He states that it may 
be given with the greatest safety to the youngest child, "its effects 
being, of course, duly watched." The dose for a child six years old is 
one-fifteenth of a grain, and, for a younger one, from one-eighteenth to 
one-twentieth of a grain, three times a day. Dr. Neligan speaks, how- 
ever (loc. cit., p. 62), of substituting the yellow iodide of mercury for 
the iodide of arsenic in the case of a child three years and a half old, 
being afraid to give the latter to so young a child. He nevertheless 
gave this remedy afterwards in the case referred to, but in the dose 
only of the twenty-fourth of a grain every morning. It is given to 
children in the state of powder mixed with sugar or aromatic powder, 
and produces, when the system is saturated with it, some constitutional 
symptoms, as acute headache, dryness of the throat, &c. He has given 
it, however, in some cases, in full doses for several weeks without any 
manifestation of its effects, further than those produced upon the dis- 



946 FAVus. 

ease. When it does give rise to constitutional symptoms, its use is to 
be intermitted for some days, and an active purgative administered. 

The local treatment of favus is undoubtedly that upon which we must 
chiefly rely, since the essential element in the treatment must always 
be the destruction of the parasite. 

The mere application of remedies adapted for this purpose, called 
parasiticides, is, however, rarely of itself sufficient, since they cannot 
penetrate to the hair-follicles, and it is, therefore, directed by most au- 
thors of experience in the treatment of this disease, that the hairs must 
be removed from the affected parts before the application can be efiici-, 
ently and successfully made. Before doing this the crusts must be re- 
moved. Some recommend for this purjDose poultices, but these are 
condemned by Wilson^ as clumsy, and by Lebert as causing the exten- 
sion of the disease by the softened sporules which spread to the sur- 
rounding surfaces and propagate the disorder. This objection does 
not, however, appear valid, and their use is countenanced by many 
good authorities. Wilson recommends their removal by means of a 
local vapor-bath, applied through the medium of a caoutchouc cap^ or, 
if this is not at hand, by laying a piece of folded lint, wetted in a solu- 
tion of subcarbonate of soda or potash, upon the head, and covering it 
with an oiled silk or gum elastic cap, which should include the entire 
scalp. M. Lebert insists upon the necessity of removing the favi (not 
the pustular crusts which accompany the specific vegetable growth), in 
their dry state, by means of small spatulas, needles, or some kind of in- 
strument. The epidermis is readily detached from around the favus, 
and this latter, which adheres but slightly to the skin, is then easily 
removed. M. Lebert states that this is so easily done, that he has 
been able to teach his ward-attendants to remove them without pain 
to the patients. Hebra uses applications of alcohol which cause the 
crusts to shrink and thus lose their attachments, when they are readily 
removed. 

After the crusts have been gotten rid of, the scalp should be well 
washed with soap and water in order to remove any favous sporules 
that may have escaped and become free, and the hair should then be 
cut short. Yarious applications are then recommended, before pro- 
ceeding to epilation, as tending to allay the irritability of the scalp and 
to render the hair less friable; among these are oil of cade (Bazin) and 
almond-oil (Anderson), which may be applied for a few days before epi- 
lation is begun. There are various methods which have been adopted 
for the extraction, but the best is undoubtedly to employ a small pair 
of forceps with square ends, and fine but not sharp teeth, so as to enable 
the operator to catch the delicate and brittle hairs surely without break- 
ing them. The hairs must be extracted singly, and so soon as a little 
space has been cleaned, the parasiticide remedy should be applied so as 
to secure its entrance to the follicle. A single epilation is frequently 
not sufficient, but it is easy to distinguish^ by the appearance of the 
surface and the growing hairs, those parts where the disease has been 
eradicated. This process is at first somewhat tedious both to operator 



TREATMENT. 947 

and patient, T^ut by practice a degree of skill is acquired which enables 
the physician or trained nurse to remove the hair rapidly and with 
very little discomfort to the patient. 

So soon as a clean surface has been thus obtained, some application 
intended to destroy the vitality of the vegetable growth ought to be 
made use of. One of the best for this purpose is a solution of corrosive 
sublimate, the strength of which, according to Lebert, ought to be, when 
employed in lotion, from two to four grains to the ounce, and, when 
used as a fomentation, weaker. This is also McCall Anderson's favorite 
application. Dr. Bennett (^Banking's Half- Yearly Abstract, No. xii, 1850, 
Am. ed., p. 73), employs, to fulfil this indication, cod-liver oil. The head 
is kept constantly smeared with the oil, and covered with an oiled silk 
cap. This application is, however, merely jDalliative, and, so soon as it 
is intermitted, the disease reappears. 

There are various other remedies that have been applied to the dis- 
eased scalp empirically, either to " modify the state of the skin,'Ho 
" excite the disordered follicles to healthy action," or, lastly, to " destroy 
the vitality of the fungus, and, by altering the nature of the soil on 
which it flourished, to prevent its reproduction." Without attempting 
to define the mode in which any of these various substances may pro- 
duce their eifect, we deem it best to mention as succinctly as possible 
those which have the strongest testimony in their favor. 

Mr. E. Wilson, who it will be remembered does not believe in its para- 
sitic nature, is less favorable to strong applications than he was for- 
merly. Those he now prefers are the ceratum tiglii^ containing from 
ten to thirty drops of the oil to the ounce; the unguentum hj^drargyri 
nitratis, diluted one-half; the unguentum hydrargyri nitrico-oxidi, 
diluted in similar proportion; the. compound sulphur ointment, and 
some others. 

Dr. Bennett's application of cod-liver oil has been referred to above. 
This, in connection with the constitutional treatment for scrofula, is 
said to have cured, on an average, in six weeks. 

MM. Cazenave and Schedel recommend alkaline and sulphurous ap- 
plications, and acidulated lotions. They speak very favorably of, and 
give much the highest place, amongst the substances to be used in 
friction, to the iodide of sulphur. This remedy was originally made 
use of by Biett, and employed by him with much success. Its efficacy 
is attested also by Lebert. It is used in the form of an ointment, con- 
sisting of from a scruple to half a drachm of the drug to an ounce of 
lard, which is to be applied morning and evening to the diseased sur- 
faces by gentle friction. 

Applications of hyposulphite of soda, in proportion of ^j to f^j of 
water, or of sulphurous acid lotions, are highly recommended. Among 
the parasiticides most valued in France, are oil of cade and turpeth 
mineral, which latter may be employed in the proportion of 5j to f^j 
of glycerin of starch, which is perhaps the best excij^ient for the various 
parasiticides. 



948 TINEA. 

Ointments and lotions containing carbolic acid have been much em- 
ployed of late, but apparently not with entire success. 

Dr. Fuller recommends the ablution of the head twice a day by means 
of soft soap, and the inunction of an application composed of equal 
parts of unguentum hydrargyri ammonio-chloridi, and unguentum picis 
liquidse. He states that a cure may usually be effected by this plan in 
from two to four weeks. 

Under any plan of treatment, a complete cure is rarely obtained in 
less than from four to eighteen weeks; the disease is extremely obsti- 
nate and there is a strong tendency to the redevelopment of the parasite 
after the cessation of the local treatment, until it be completely eradi- 
cated. By persevering in the plan above recommended, however, this 
can invariably be effected, and a perfect cure obtained, with the excep- 
tion of patches of baldness, which but too frequently follow, from the 
destruction of the hair-follicles. 



AETICLE II. 

TINEA. 



We have already, in our general remarks introductory to this chap- 
ter, stated our belief that the various forms of tinea or ringworm are 
contagious diseases, and due to the presence of a peculiar fungus, the 
tricophyton. 

The ordinary varieties of tinea which are described, are tinea tonsu- 
rans, or ringworm of the scalp; tinea circinata, or ringworm of the 
general surface; and tinea sycosis^ or ringworm of the beard. With 
the latter form, of course, we are not at present concerned, nor are its 
relations to the two other varieties indisputable, since opinions are still 
divided as to its contagious and parasitic nature. 

There is, however, abundant reason for believing the essential identity 
of tinea tonsurans and tinea circinata. In addition to the results of 
microscopic examination, which reveals the presence of the same fungus 
in both, there is the strongest clinical testimony to the same effect. 
Thus it constantly happens that patches of the two varieties will be 
observed upon the same patient, and there are innumerable instances 
on record to prove that they give rise to each other. 

These diseases have been described by some authors under the generic 
name of porrigo; by others under that of herpes. Wilson, in his last 
edition, employs the term trichinosis to designate the group. 

Causes. — The peculiar parasite is the essential cause of the disease ; 
and the mode of its propagation is chiefly by contagion. Mr. Wilson 
believes the cause of the disease to be imperfect nutrition ; but it is quite 
certain that the only way in which a scrofulous or debilitated constitu- 
tion can influence the production of the disease, is by favoring the more 



SYMPTOMS OF TINEA TONSURANS. 949 

ready growth of the parasite. In like manner, dirtiness of every kind 
may be said to be a predisposing cause. 

The influence of these is, however, trifling, and we have frequently 
met with the disease among families living in easy or very afliuent cir- 
cumstances, the children of which were perfectly well lodged, well 
clothed, and well fed, and to whom every attention required by the 
nicest cleanliness was given. The means by which the afl'ection is com- 
municated are such as brushes, combs, caps, &c., or by the direct con- 
tact of the diseased surfaces. 

One of us has but lately had an opportunity of studying, on a. large 
scale, these afl'ections and the mode of their transmission, at a large 
Children's Home in this cit}'. There were a considerable number of 
children, about twenty in all, affected with the disease in a severe form ; 
by strict isolation, by the utmost care in preventing any use of their 
combs, brushes, caps, or clothing, by the other children, by covering 
the entire scalp with an oiled-silk cap, whenever they mingled with 
their comrades, the disease was prevented from spreading. It w^as, 
however, frequently observed, that in the children who sufl'ered with 
tinea tonsurans of the scalp, patches of tinea circinata would appear 
either on the neck or face, or on some part which could be brought in 
contact with the afl'ected surface; and its highly contagious nature was 
unhesitatingly believed by all the attendants, who had indeed them- 
selves furnished the strongest evidence possible of it, by each and all 
contracting the disease repeatedly from handling the children in dress- 
ing them, or in making applications to the afl'ested parts. 

Age exercises a marked influence upon the production of these dis- 
eases, tinea tonsurans being confined to childhood and early youth, 
most commonly occurring between the ages of three and twelve years; 
though tinea circinata may be met with at any age. 

Tinea Tonsurans. — Symptoms. — Those who regard this disease as a 
variety of herpes, describe its first appearance as a ring of minute vesi- 
cles; this, however, is not essential, and the disease most frequently 
begins with little erythematous patches, which increase circumferen- 
tially while they heal in the centre, leaving the skin more or less fur- 
furaceous. When fully established, the disease appears in the form of 
furfuraceous patches of oval or circular shape, which are at first not 
more than ith or ith of an inch in size, but which increase gradually 
until they attain a diameter of one or two inches, and seldom more. 
The diseased surface is slightly thickened, elevated, of a grayish, bluish, 
or slate color, and covered with fine dry scales, which are very easily 
rubbed off, and are quickly renewed after being removed by any cause. 

The hairs are altered, from the very first. In the early stage, the 
apertures of the follicles of the diseased hairs are generally more or 
less prominent or papillated, and the hairs are unnaturally brittle, dull, 
and dry, and are bent on themselves and twisted, so as not to lie smooth, 
and the roots are somewhat matted together by the furfuraceous scales. 
A little later, they break off at a short distance from the diseased sur- 
face, leaving the circular patches partially deprived of hair. The broken 



950 TINEA. 

hairs are uneven in length, and otherwise altered in appearance, being 
bent and twisted, and having become lighter in color than the original 
hairs, so as to assume somewhat the look of bundles of tow. The en- 
larged follicles also dot the surface, giving it the appearance of cutis 
anserina, or the skin of a plucked fowl. The epidermis and the stumps 
of the broken hairs now become covered with a characteristic grayish- 
white powder, consisting of the sporules of the tricophyton, the pecu- 
liar parasite; and, on examining the hairs, the same fungus will be 
found penetrating into the bulbs and shafts between the separated 
fibres,, and causing here and there, by its accumulation, swellings or 
bulgings of the shaft. 

The disease is unattended by any local sensations, excepting a mod- 
erate degree of itching. 

If the disease persist and the degree of inflammation increases, there 
maybe a good deal of infiltration of the scalp, and the surface becomes 
tumid, and dotted with enlarged orifices of hair-follicles, or there may 
be an eruption of vesicles or pustules, which dry and form scaly, yel- 
lowish crusts. 

Diagnosis. — This disease is easily distinguished from other eruptions 
of the scalp. The appearances it presents when fully developed, are 
utterly unlike those of favus or eczema impetiginodes capitis. In favus, 
the peculiar cup-shaped crusts and the presence of the spores of the 
achorion, are sufficient to prevent mistakes; while in eczema, the erup- 
tion is«ero-pustular, with the formation of yellowish or brownish yellow 
crusts; the patches are not circular, the hairs are healthy, the itching 
is extreme, and finally the disease is not contagious; in all of which 
particulars it differs entirely from the eruption of ringworm. 

Pityriasis capitis does not occur in circular patches, but affects the 
whole scalp ; it is not parasitic nor contagious, and does not lead to so 
much alteration of the hairs. 

Occasionally tinea tonsurans, either from the irritation of scratching, 
or some other cause, may be associated with eczema impetiginodes, 
w^hich to a great extent obscures the former disease, though a careful 
search will usually detect some of the characteristic broken stumps of 
hairs, loaded with the parasitic growth. 

Prognosis. — Eingworm of the scalp is entirely devoid of danger, but 
is an exceedingly troublesome disease, as it is apt to spread to other 
children, and is often very difficult of cure. Its duration is very indefi- 
nite, and it not rarely leads to patches of permanent baldness. 

Tinea circinata, as we have already said, frequently occurs in con- 
nection with tinea tonsurans, appearing on the neck or face; though it 
occurs also as an independent disease on any part of the body, and in 
patients of every age. 

It begins as a little rose-colored, slightly elevated spot, which soon 
becomes the seat of slight furfuraceous desquamation; and extends cir- 
cumferentially, healing in the centre, until it forms a large slightly ele- 
vated erythematous ring, inclosing a portion of sound skin. 

In other cases, minute vesicles form on the reddened inflamed ring. 



TINEA CIRCINATA — TREATMENT. 951 

They follow the usual course of development, being at first transparent, 
then turbid, and finally drj'ing into small thin scales. 

The size of the patch varies greatly, beiug in some instances small, 
not larger than a shilling, and in others presenting a diameter of two 
or three inches. When small, the redness covers the whole of the 
patch, but is much fainter in the centre than at the circumference; 
when large, the centre regains the natural color of the skin. Usually 
the ring is exactly circular, but at times it assumes an oval shape. 

If any hairs have been growing on the afi'ected spot, they become 
brittle and changed, as before described. There are usually several 
such circles present, and in some cases they are formed in great num- 
bers. The only symptoms accompanying the eruption are slight prick- 
ing, smarting, and itching in the part. 

Diagnosis. — There are but few diseases with which there is any 
danger of confounding tinea circinata. It is distinguished from ery- 
thema circinatum by the greater elevation of the marginal ring, by the 
presence of the parasite, and by its contagious nature ; and the two 
last peculiarities serve to distinguish it from psoriasis circinata. 

According to McCall Anderson, and some other dermatologists, 
herpes iris is merely a form of this aff'ection. 

Treatment. — The cases of tinea tonsurans that have come under 
our charge, have proved in man}^ instances very rebellious to treatment. 

Strict attention should always be paid to cleanliness and hygienic 
rules; and, if the disease be associated with any impairment of the 
constitution, cod-liver oil, iron, in the form of the syrup of the iodide 
in syrup of sarsaparilla, arsenic, and bitter tonics, should be adminis- 
tered. 

The local treatment is, however, the most essential. Where the dis- 
ease occurs on a part covered with hair, epilation is advised by some 
authorities, and it would in all probability facilitate and hasten the 
cure. 

Among the local applications which have proved most useful to us 
have been sulphuro-alkaline lotions, composed of 5j of subcarbonate of 
potash and 5ij of sulphur, to a pint of water, applied by washing with 
a sponge several times a day ; strong solutions of sulphite of soda; and 
an ointment consisting of 3j of muriate of ammonia, mixed in an 
ounce of sulphur ointment, applied first at night by inunction, and 
after a time on rags. 

Alkaline remedies have also been much used by other observers, who 
recommend washing the scalp every morning with a lotion composed 
of gr. XXX or xl of carbonate of potassa or borax to a pint of water, 
and applying in the evening an ointment containing 9j of tannic acid 
to ^j of lard. 

Much more stimulating applications are, however, highlj^ recom- 
mended, and often prove very serviceable. Thus Mr. Wilson advises a 
single application of the acetum cantharidia, or the stronger acetic acid ; 
and Devergie recommends a solution of nitrate of silver, 5j to f5J of 
water. 



952 TINEA. 

Yarious mercurial applications are also advised, as solutions of cor- 
rosive sublimate, the citrine ointment, or the following, recommended 
by Jenner : 

^. — Hydrargyri Ammonio-Chloridi, .... gr. xx. 
Ung. Sulphuris, ^iv. 

Tarry applications may also be employed in obstinate cases, in the 
form of lotions, ointments, or soaps, containing tar, or oil of cade. 

Nayler speaks highly of a plan used by Mr. Coster, who saturates 
the part wnth the following mixture : 

R.— lodini, 5ij. 

01. Picis, . fgj. 

This solution is to be rubbed in firmly with a piece of sponge on the 
end of a piece of wood or whalebone. It is allowed to drj^on the part^ 
and left until the cuticle and the black crust sej^arate at the end of a 
week or ten days. 

In cases where many patches are present over the body, it is advis- 
able to employ mercurial or sulphur vapor baths. 

It must not, however, be forgotten that these varieties of tinea are 
among the most obstinate disorders to which children are subject. 
The most faithful trial may be made with the remedies recommended 
above, for a long time, without success, and it is often necessary to 
persevere in their use for months; conjoining the treatment with a 
change of diet, and, when possible, with a change of residence, before 
the alfection will be entirely and permanently cured. 

Cases. — The following cases may be taken as types of the aggravated 
form of tinea, after it has persisted a longtime and beconie complicated 
with secondary eruptions of eczema or pityriasis. It will be noticed 
that in the following records, all of the patients are stated to have been 
markedly scrofulous ; but this circumstance must not have too much 
importance attached to it, since in the Home where these cases occur- 
red, almost every one of the children presented unquestionable marks 
of the strumous diathesis. There can be no doubt, however, that this 
condition of constitution strongly favored the development of the dis- 
ease, rendered it more severe and obstinate, and also favored the occur- 
rence of the secondary inflammatory eruptions. 

George T., set. five, scrofulous, admitted to the Home in 1864, with 
bleeding piles. Tinea tonsurans appeared two months after admission, 
and persisted with various fluctuations for eighteen months, when it 
became complicated with eczema impetiginodes. Applications of tar 
and corrosive sublimate have been chiefly relied on. 

Nov. 30th, 1866. Scalp covered with grayish-yellow crusts, one- 
fourth inch thick, in places running together or forming isolated lumps. 
A few spots of tinea circinata on face and neck. The scalp is reddish, 
and there is very little discharge from it. The hairs are sparse and 
broken. The cervical glands are much enlarged on both sides. On 



CASES. 953 

removing the crusts and examining the base, numerous exudation cor- 
puscles, and some spores of tricophyton were found ; the epithelium 
not very granular. 

Poulticed to remove the crusts. Ordered iodide of iron and potas- 
sium internally. 

Dec. 4th. Scalp quite clean from crusts, but remains reddish, with 
here and there bald patches. Numerous spores of tricophyton found 
in the hairs and among the epidermic cells. 

Solution of sodse sulphis (3J to Oss. water), applied morning and even- 
ing, and kept on during the whole time by means of folds of linen satu- 
rated in the solution, and covered with an oil-silk cap. 

Dec. 16th. Much improved. Scalp cleaner, and less red. Some flat, 
thin, whitish scales over surface. Hairs more free from tricophyton, 
but numerous spores can still be seen by scraping moist surface beneath 
the thin crusts. 

Treatment continued, with ultimate success. 

William L., set. 5; hereditary tendency to tuberculosis; scrofulous; 
cervical glands enlarged on both sides; admitted in 1865, and has had 
tinea ever since, many forms of treatment having been tried, but none 
with more than temporary success. 

IS"ovember 30th, 1866. The scalp is reddened and wax-like from in- 
filtration, with patches of baldness. In places where the eruption is 
oldest it is covered with whitish scales; elsewhere, there are scattered 
or confluent grayish-yellow or yellow crusts. Discharge of pale, thin, 
fetid pus. 

On examining the surface beneath the crusts, numerous pus-cells and 
spores- of tricophyton, often aggregated together, are found. The hairs 
have lost their normal appearance entirely, are bent, and where they 
emerge from the scalp, the shaft is swollen, with bulging outline. The 
shafts are covered with spores of tricophyton, and their longitudinal 
fibres separated by collections of the fungus. Some of the bulbs remain 
healthy, others are broken and apparently converted into masses of fun- 
gous sjDores. 

Ordered poultices to remove crusts; iodide of iron and potassium in- 
ternally. 

December 4th. Scalp clean, with exception of minute white scales; 
shows bald glazed patches, with light, short, thin hairs. Ordered same 
application of sulphite of soda as used in previous case. 

December l5th. Immensely improved; the large bald patches still 
covered with minute shining white scales, but few tricophyta to be 
seen. 

Charles L., let. 4, admitted in May, 1866 ; hereditary tendency to 
tuberculosis; cervical glands slightly enlarged. Tinea soon appeared 
on the face and scalp, and in early part of November, thin flat grayish- 
yellow crusts formed over vertex, the rest of the scalp being covered 
with minute whitish scales. 

November 30th, 1866. Ordered poultices to remove crusts; iodide of 
iron and potassium internally. 



954 ALOPECIA AKEATA. 

December 4th. Scalp comparatively clean. Patches of baldness, es- 
pecially over parietal protuberances, with straggling, short, light-colored 
hairs. Abundant spores of tricophyton found. The hair-shafts much 
involved, collections of the parasite existing between the longitudinal 
fibres. The bulbs are also diseased, and seem to have become affected 
just below the exit of the hair; the bulb first becoming swollen at this 
l^oint and then its sheath having become destroyed, so that the fungus 
forms a bed surrounding the shaft. 

Ordered same application of solution of sulphite of soda. 

December 16th. Yery much improved; scalp smooth and clean, ex- 
cepting above the ears, where there is on each side a collection of thin 
yellowish crusts. The hairs passing through these had numerous pus- 
cells adherent to their shafts, but the hair-bulbs seemed healthy, and no 
spores of tricophyton could be found on any of them. 



AETICLE III. 



ALOPECIA AREATA. 



This affection, which is also known by the names of area and tinea 
decalvans, is characterized by the loss of hair in circumscribed patches 
of round or oval shape. It is by no means a rare disease, and is much 
more common in children than in adults; thus of 42 cases cited by 
Hutchinson, 28 were under fifteen, 14 above that age. 

Cause. — There is still much doubt as to the essential cause and na- 
ture of alopecia areata. 

Grruby is said to have discovered in 1843 a fungus in it, which has 
been called the microsporon Audouini, and some dermatologists of high 
authority accept the view of its parasitic nature. It cannot, however, 
be said to be demonstrated, since the parasite is very rarely found; 
so that Anderson, who has made numerous microscopic examinations, 
has never succeeded in detecting it. 

Wilson considers it as due to suspended innervation, as a kind of 
paresis. 

The disease appears to be, at least in some instances, propagated by 
contagion; though it certainly possesses this property to a much less 
degree than either of the forms of ringworm. 

Symptoms. — The disease is limited to the scalp in children ; though 
in adults it may attack any hairy part. In some cases, the first inti- 
mation of tbe existence of the disease is the sudden discovery of a bald 
spot, but in others, though less frequently, there is slight itching, with 
redness and branny desquamation of the affected spots. 

The bulbs of the hairs then atrophy, and become tapering instead of 
being rounded and club-shaped; the hairs themselves become dry, lus- 



DIAGNOSIS — PROGNOSIS — TREATMENT. 955 

treless, and brittle, with a fibrous fracture, and rapidly fall out; leaving 
bald patches. 

These patches vary in size from one-half inch to an inch or even 
more in diameter^ and there may be but a single one present, or they 
may be numerous, in which case they often coalesce, forming large 
patches of irreguhir shape; when the patches are single they usually 
assume a round or oval form. 

The denuded portion of scalp is peculiar in appearance, being very 
white and polished, and thinner than the surrounding healthy scalp; 
the sensibility of the affected surface is also frequently impaired. 

Diagnosis. — There can be no difficulty in recognizing the fully de- 
veloped disease, excepting in the comparatively rare cases when it is 
combined with other skin diseases, as eczema or pityriasis. 

Prognosis. — The only danger attendant upon alopecia areata is that 
of deformity, which is, in some cases, very great, depending of course 
npon the extent of the disease and the stage at which it is brought 
under treatment. 

If the patches are small, the scalp not materially atrophied, and the 
orifices of hair-follicles still visible on the bald patches, there is good 
reason to hope that steady persistence in treatment will effect a cure. 

Treatment. — Those who regard this as a parasitic affection, advise 
the ablation of the hairs immediately surrounding the patch, and the 
application of some of the stimulating parasiticides recommended in 
the article on tinea. 

The majority of authors, however, content themselves with the ap- 
plication merely of such stimulating lotions and ointments as will in- 
crease the nutrition of the affected spots, and favor the renewed growth 
of hair. 

Among the ointments which are most highly recommended are those 
containing the red iodide, the nitrate, the ammonio-chloride of mer- 
cur}^; some form of sulphur; or tar, iodine, or cantharides. 

Hillier recommends, as the treatment he has found most useful, the 
application at long intervals of acetum cantharidis to the bald patches; 
painting them every other day with tincture of iodine, washing the head 
twice a week with soap and cold water, and applying a wash (consist- 
ing of one pint of rum, one ounce of tinct. cantharidis, one-half ounce 
of spirit, amraonise aromat., and ten ounces of water) to the parts of 
the head which are not bald, twice a week. 

The effect of this local treatment will be much increased by the in- 
ternal administration of arsenic and iron. 



956 SCLEREMA. 

SECTION II. * 

AETICLE I. 

SCLEREMA. 

Definition; Synonyms; Cause; Frequency. — This peculiar affec- 
tion, characterized by induration of the skin and subcutaneous tissue, 
with or without oedema, has been described by numerous writers, al- 
most each one of whom has given a distinct name and theory for tbe 
disease. Among these names the most appropriate are sclerema, scle- 
riasis, scleroderma, induration of the cellular tissue, or chorionitis. 

It is an affection not altogether peculiar to infants, though it is rare 
to find it Avell developed after the first few months of life. There are, 
however, a sufficient number of cases in adults on record to establish 
the fact of its occasional occurrence at all ages. It must be a very rare 
disease in this country, even among infants, and especially in private 
practice, as we have met with but three well-marked cases in adults, 
and but one instance occurring in childhood, which was the case in 
which imperfect induration of the skin was developed in connection 
with atelectasis pulmonum, to which allusion is made in our article 
upon this latter affection. 

In the large foundling hospitals in Europe, however, where so many 
causes exist to depress the vitality of the infants, it is of very frequent 
occurrence. Under such circumstances, moreover, it generally devel- 
ops itself within the first twelve or fourteen days after birth. 

The most varied causes were formerly assigned for this disease, be- 
fore the researches of Bailly and Legendre appeared to point out scle- 
rema as one of the results of imperfect expansion of the lungs. As we 
have already remarked, it is seldom observed among the children of 
the upper classes of society, so that all those conditions which depress 
the strength of the child, as insufficient or unhealthy nourishment, im- 
perfect clothing, cold, especially when associated with moisture, may 
be considered as the predisposing causes of sclerema. The influence of 
dampness and cold in developing this affection is shown by the fact, 
deduced from numerous statistics, that twice as many children are 
attacked during the cold and wet months of the year as at other 
times, although there are cases recorded as occurring in the hottest 
months. 

Authors still differ in regard to the relation between atelectasis and 
sclerema. West^ accepts the results of the researches of Bailly and 
Legendre, and considers it a result of the imperfect expansion of the 

1 Diseases of Children (3d Amer. ed.), p. 238. 



SYMPTOMS. ^ 957 

lungs. Bonchut/ on the other hand, regards the changes found in the 
lungs as the result rather than the cause of the induration of the skin. 

Letourneau- agrees with West in regarding sclerema as a condition 
depending primarily on congenital weakness, imperfect expansion of 
the kings and defective hgematosis. According to his view it is a slow 
asphyxia, the body becoming gradually cooled down and the child re- 
maining in a state of organic torpor until death occurs. 

Symptoms. — The disease presents some variety of symptoms accord- 
ing as it occurs in early infancy or in more advanced life. 

In infants the induration of the skin appears within two weeks after 
birth, either with or without a preceding febrile condition for a day 
or two. It invades successively the feet, hands, limbs, the back, the 
face, and finally involves the entire surface of the body. At this early 
age, the skin retains its reddish tint in the affected parts; whilst later 
in life, the surface assumes a dull, slightly yellowish aspect. The skin 
becomes hard, is with difficulty pinched up, and instead of thinning, 
remains thick and waxlike. The parts appear somewhat swollen, 
though never to any great extent, and pressure with the finger 
scarcely leaves an impression on their surface. Occasionally the in- 
duration is associated with an effusion of serum beneath the skin, and 
when this exists, the surface is much more readily indented. 

It is this occurrence of oedema which has led some observers to con- 
sider sclerema as a form of anasarca; it is probable, however, that its 
presence is merely a result of the obstructed cutaneous circulation, and 
that it docs not, in reality, constitute an essential element of the dis- 
ease. The skin is also quite frequently jaundiced. The children usually 
preserve the power of moving the affected parts, and there is no loss of 
cutaneous sensibility. The temperature of the body, and especially of 
the indurated portions, rapidly decreases, so that from 100° it may fall 
to 90°, 80°^ and even, in some exceptional cases recorded by Roger, to 
73° and 70°. 

The little patients appear to suffer much pain during this disease. 
They utter a sharp, abrupt, isolated, but very frequently repeated cry, 
quite characteristic of the affection, and occasionally they present ner- 
vous sj^mptoms, such as twitching of the hands or more general con- 
vulsive movements. 

The strength fails rapidly, and they soon become too weak to suck. 
The pulse is feeble, though not much accelerated, unless some complica- 
tion has ensued. The appetite fails, and the bowels are constipated, 
unless there is entero-colitis, which occurs in a few cases. This con- 
dition is naturall}^ attended with great emaciation, as we find in El- 
saesser's^ cases, where the average loss of weight was three-fourths of a 
pound, the extremes being six ounces and two pounds. 

The respirations are imperfect, and, after a short time, cough makes 



^ Diseases of Infancy (Bird's trans.). 

2 Letourneau, Sclerema and (Edema. Paris, 1858 (Canstat. Jahrb., iv, 456). 

3 Sclerema, Arch. Gen. N. S., t. i, 1853, p. 531. 



958 SCLEREMA. 

its appearance and continues throughout the case, indicating the occur- 
rence of either pneumonia or collapse of the lungs, which are by far the 
most frequent complications, even if the state of atelectasis be not re- 
garded as an eflScient cause of sclerema. The disease, however, is not 
always so general and severe as above described; occasionally it occurs 
in limited portions of the body, and without any very alarming symp- 
toms. 

In later life the disease is more frequently thus limited to small por- 
tions of the body; the symptoms follow a more chronic course, and are 
somewhat amenable to treatment. Eilliet and Barthez^ describe an 
acute and chronic form, and mention the following symptoms as distin- 
guishing the disease in the adult: the severe epigastric pain associated 
with violent palpitations, the less acute progress of the case, and the 
more frequent implication of the serous membranes. 

In one well-marked case, occurring at the age of thirty-five years, 
which one of us had the opportunity of observing during its entire 
course, these symptoms were very prominent. 

Prognosis. — In infants, when the induration is at all general, the dis- 
ease almost invariably terminates fatally in from two to six days. Under 
favorable circumstances, however, and when the induration is limited, 
resolution may occur, and the case terminate favorably; though it re- 
quires from fifteen days to a month to eff'ect the cure. 

The fatal result is either caused by the gradual exhaustion of the 
vital powers, or by the supervention of one of the complications already 
mentioned, by far the most usual of which are lesions of the lungs. 

In later life, when the disease tends to recovery, a long time may be 
consumed before the induration completely disappears. Eilliet and 
Barthez report a case, occurring in a girl aged eleven years, which lasted 
two years, although it was at no time very general or accompanied by 
very severe symptoms. 

Of 53 cases reported by Elsaesser, all but 4 proved fatal, either from 
the sclerema itself, or from some incidental disease. 

Diagnosis. — The absence of any lesion of the internal organs, together 
with the perfectly characteristic appearances of the induration, render 
an error of diagnosis almost impossible. 

Anatomical Appearances. — The induration of the surface persists 
after death, and on incising the part, a turbid fluid, resembling that of 
anasarca, often flows out. The subcutaneous tissue is also indurated, 
and the fat is found in the form of solid granules. This layer, which 
varies from one-half a line to three lines in thickness, is sometimes fol- 
lowed by a gelatinous one. 

The fluid which is contained in the meshes of the tissues has been 
subjected to analysis by several observers, but with conflicting results: 
Chevreurand Breschet reporting that it contained a plastic matter, 
sj)ontaneously coagulable on contact with the air, which they were in- 
clined to regard as characteristic of the disease; whilst Billard, on re- 

1 Op. cit., t. ii, p. 106. 



ANATOMICAL LESIONS — TREATMENT. 959 

peating this observation with fluid derived from an ordinary case of 
anasarca, found it to possess the same property. This subject, there- 
fore, of much importance in regard to the pathology of sclerema, re- 
quires to be more fully investigated. 

The indurated tissue is traversed bynumerous vessels, permeable, and 
for the most part gorged with dark blood. Bouchut believes that the 
cutaneous capillaries are in great measure obliterated in the indurated 
parts, and that the oedema which occasionally coexists with sclerema 
is due to this obliteration; founding his opinion upon an unsuccessful 
attempt to inject the skin of a limb affected with sclerema, although 
the injecting fluid freely entered all the deeper tissues. The observations 
of Elsaesser, however, render this view doubtful, since in 49 cases, he 
failed to find this condition.^ 

Apart from these morbid changes in the skin and subcutaneous tissue, 
there is no lesion characteristic of sclerema. In a large number of cases, 
however, the lungs present some abnormal condition. According to 
Bouchut, they are often gorged with blood, and here and there contain 
patches of lobar pneumonia; conditions which he regards rather as the 
result than the cause of sclerema. 

Elsaesser found lobular pneumonia present in a tenth of his cases; 
and in a third of them, portions of the lungs were impermeable to air. 
We have already stated that West, following the researches of Bailly 
and Legendre on atelectasis, believes that sclerem.ais one of the results 
of this persistence of the foetal condition of the lung, not differing in 
its essential nature from oedema following pulmonary obstruction. The 
occurrence of undoubted cases of sclerema in the adult, and the fre- 
quent absence of atelectasis in well-marked cases of sclerema in in- 
fants, appear, however, to render this view untenable. 

The entire venous system and the cavities of the heart are distended 
with dark fluid blood ; but the heart presents no constant condition to 
which could be attributed the production of the disease. The jaundice 
which has been mentioned as occasionally existing, is not found to be 
associated with any abnormal condition of the liver, excepting conges- 
tion. Entero-colitis is a rather frequent complication of sclerema, and 
has been regarded as influencing its development; but this view has 
long since been abandoned. Elsaesser found intestinal lesions and hy- 
persemia of the abdominal viscera quite commonly ; and, in eight of 
his cases, peritonitis was present. 

Treatment. — The preventive treatment of sclerema consists in atten- 
tion to all the hygienic conditions of the young infant. 

1 We have only space for a reference to the elaborate paper on keloid, scleriasis, 
and morphoea, by Dr. Hilton Fagge [Guy ^ s Hospital Reports^ 3d S., vol. xiii, 1867, p. 
255), in which the clinical history of sclerema in the adult is fully detailed ; and to 
the valuable contributions to the pathology of this disease by Rasmussen (Trans, in 
Edin. Med. Jour., vol. xiii, part i, pp. 200 and 318). According to this latter ob- 
server, the essential element in the changes of the skin in sclerema consists in a 
marked development of lymphoid cells, by multiplication of the cells in the peri-vas- 
cular sheaths of the minute bloodvessels of the derm and subcutaneous tissue. 



960 SCLEREMA. 

The curative ti'eatment implies the removal of all the causes, aud the 
application of remedies calculated to restore the force of the circula- 
tion, and the function of the skin. Warmth stands foremost as a cura- 
tive measure, and recourse may be had to warm baths or hot vapor 
baths, and to frictions with hot oil ; hot sand or bran-bags may be ap- 
plied to the surface, and the temperature of the room should be care- 
fully regulated. 

The child should be nourished with breast-milk ; and stimulants, such 
as wine-whe}^ should be freely given. Cordial and aromatic draughts 
are also recommended, which may be formed of any of the diffusible 
stimulants. 

As there is reason to believe that some relation exists between 
sclerema and atelectasis pulmonum, we should, in addition, resort to 
all those means especially adapted to remove this condition, for a full 
account of which the reader may refer to the article on collapse of the 
lungs. 

The same plan of treatment is advisable in cases in adult life. 

Ey these means we ma}^ hope to arrest, and even cure this strange 
affection, when it has not involved any considerable portion of the 
surface. 



CLASS VIII. 

AYOEMS m THE ALIMENTAEY CAl^AL. 



GENERAL REMARKS. 

There are five different species of worms found in the alimentary 
canal. These are the Ascaris liimbricoides, or round-worm; Ascaris 
vermicularis, thread-worm, seat-worm, or, as it is popularly called, as- 
carides; Tricocephalus dispar, or long thread-worm; Taenia solium, and 
Taenia mediocanellata, the most common varieties of tape-worm; and 
the Bothriocephalus latus, taenia lata, or broad tape-worm. 

We shall give a short description of each of the intestinal entozoa, 
in order that they may be readily distinguished, but will treat of the 
causes, symptoms, and treatment onlj^of the first two, inasmuch as the 
tsenias very rarely exist during infancy or childhood, and the tricoceph- 
alus is much less frequent than the round and seat-worms, and gives 
rise to symptoms of the same kind as the former. 

Description. — The Ascaris liimbricoides, or, as it is commonly called, 
lumbricoides, lumbricus, or round-worm, is shaped not unlike the com- 
mon earth-worm, having a cylindrical body, which is attenuated 
towards either extremity, but particularly the anterior. It varies in 
length generally between six and twelve inches, and is usually about 
two or three lines in thickness. The young worm, about an inch and 
a half long, is rarely met with. The head of the animal is at the 
smallest extremity, and ma}^ be distinguished by a circular depression, 
around which may be seen three tubercles. When recentl}^ voided, the 
worms are somewhat transparent, so that the viscera may sometimes 
be seen through the parietes. The integument is marked by circular 
fibres, and by four lines extending at equal distances from the head to 
the tail, the former of which indicate the course of the muscles, while 
the latter indicate that of the vessels and nerves. 

The color of the worm is whitish, yellowish, or more or less deep 
rosy in tint, according to the nature of the aliment they contain ; thej^ 
are, as already stated, somewhat transparent when first voided. The 
alimentary canal, which may be distinguished b}^ its brownish color, 
terminates by a transverse opening or anus, situated on the inferior 
surface of the animal, just in front of its posterior extremity. 

The two sexes are in different individuals. The male maybe known 
by its tail, which is shortly curved, while that of the female is straighter 
and thicker. The genitals of the male consist of a double penis, which 

61 



962 WORMS. 

may sometimes be seen to protrude just in front of the caudal extremity; 
those of the female may be distinguished by the vulva, seated at a con- 
stricted point of the body, about a third of the distance from the head 
to the tail. The male is smaller and much less abundant than the 
female. 

The Ascaris or Oxyuris vennicularis, thread-worm, seat-worm, or maw- 
worm, is the smallest of the intestinal worms, and is generally distin- 
guished in popular language by the title of ascarides. The sexes are 
in separate individuals. 

The male is generally about two lines in length ; its body is elastic, 
of a whitish color, very slender, and looks not unlike a piece of cotton 
thread, whence one of its names was derived. The female is larger 
than the male, reaching a length of four or five lines. The anterior 
part of the body is of the same shape in both sexes. It is obtuse, and 
surrounded b}- a transparent membrane, through which may be seen a 
straight tube, forming a kind of bladder, which is the oesophagus, and 
which terminates in a globular stomach. The head is provided with 
three tubercles, as in the lumbricoides. The intestinal tube in the male 
continues the whole length of the body, which becomes somewhat 
thicker towards the end, and is arranged into a spiral shape at the 
tail. The body of the female is shaped like that of the male as far 
back as the stomach, and increases in size in the first third of its 
length, after which it diminishes, and becomes so small at the end as 
to be seen with difficulty by the naked eye. 

The Tricocephalus dispar% or long thread-worm, is generally about an 
inch and a half or two inches lono;, and consists, as it were, of two 
portions, of which the anterior, constituting about two-thirds of the 
length, is exceedingly slender, scarcely thicker than a horse-hair, while 
the posterior third swells out suddenly so as to become much thicker 
and larger. The sexes are in different individuals. The worm is pro- 
vided with an alimentary canal, which, commencing at an orbicular 
mouth placed in the small extremity, runs through the animal to the 
anus, placed at the caudal extremitj'. The male is smaller than the 
female, and is, usually, found convoluted. This worm is met with 
chiefly in the coecum and colon, particularly the former. It usually 
exists in very small numbers, but sometimes but a single one is found. 
The symptoms which it occasions are the same as those produced by 
the lumbricoides. 

The Taenia solium, common or long tape-worm, as well as the Taenia 
lata, are of rare occurrence in children; Of 206 cases observed by M. 
Wavruch, only 22 occurred in subjects under fifteen years of age, and 
of them the youngest was three j^ears and a half old (Bib. du Med. 
Prat., t. V, p. 626). These worms have, however, been met with at an 
earlier age, but as they are rare, we deem it unnecessary to do more 
than describe their appearance, in order that the reader may be able 
to distinguish between them and the varieties which generally exist in 
children, the Ascaris lumbricoides and vermicularis. For a full ac- 
count of the symptoms produced by the two varieties of the taenia, and 



DESCRIPTION — FREQUENCY. 963 

their treatment, the reader is referred to any of the standard works 
on the practice of medicine. 

The Tsenia soUitm is usually of a whitish color, flat in form, and vary- 
ing in length from five to ten feet, its ordinary" length, to sixty, or 
even, according to the assertion of some writers, upwards of a hun- 
dred. It is uneven in shape, being thick and rounded behind, and 
measuring three or four lines at its widest part, while it tapers gradu- 
ally towards the anterior extremity, where it becomes slender and 
thread-like.' The head is minute in size, and flattish in shape, with a 
projecting papilla in the centre, furnished with a double circle of hooks, 
and surrounded by four cylindrical apertures, which seem to be the 
mouths of the animal. The body is composed of numerous segments, 
which are longer than broad at the posterior part of the w^orm, and re- 
semble, when separated, the seeds of a gourd, and have hence been 
called cucurbitani. In this worm the two sexes exist in the same in- 
dividual. 

The BothriocepJialus latus, Taenia lata, or broad tape-worm, is long and 
flat like the preceding variet}^, but it is generallj^ thinner and broader, 
measuring from four to ten lines in breadth. It sometimes attains, 
like the common tape-worm, to a very great length. It is usually of a 
dirty-white color, and rather less opaque than the tsenia solium. It is 
distinguished also, says Dr. Wood, from the other tsenia, by the shape 
of the segments, which are broader than they are long; by the form of 
the head, which is small, elongated, without spines, and divided into 
two lobes by a longitudinal fossa on each side; and by having, instead 
of the four mouths of the tsenia solium, a single minute pore in the 
centre, between the fossae, or else two pores, one at the extremity of 
each lobe. 

The frequency of intestinal worms, and their importance as a cause of 
disease, have certainly been, and are still by many physicians, and es- 
peciall}^ by the public, very greatly exaggerated. There can be no 
doubt that they do, \vhen they exist in large quantities, and particu- 
larly in certain countries, give rise to great disturbances of the diges- 
tive organs, and even occasion death; but such instances are, it seems 
to us, extremely rare, in this city, at least. We are quite sure that we 
have never as yet met with a case, in our own experience, in which life 
was at all seriously endangered by their existence, — though we have 
seen numerous instances in which slight disorders of the digestive ap- 
paratus, and various nervous symptoms, generally of very moderate 
severity, have disappeared after the administration of anthelmintics, 
sometimes followed, and in an equal number of cases probably, not fol- 
lowed, by the expulsion of worms. 

To show the truth of the above remarks, as to the importance of 
w^orms as a cause of disease, we make the following quotations : Dr. 
Eush {Med. Inc^uiries and Observations, vol. i, p. 205), remarks: " When 
we consider how universally worms are found in all young animals, 
and how frequently they exist in the human bod^^, without producing 
disease of any kind, it is natural to conclude that they serve some use- 



964 WORMS. 

fill and necessary purposes in the animal economy." M. Guersant says 
(^Dict. de 3Ied., t. xxx, 669) : "It has always been the custom to assign 
to entozoa much too important an influence upon the diseases of child- 
hood. In proportion as this part of pathology is perfected, it becomes 
evident that the greater number of children dying after having dis- 
charged worms, or even while having them still, are affected with acute 
or chronic diseases, which leave after death incontestable traces of their 
effects, and which are of themselves necessarily fatal." M. Barrier 
{3IaL de rJEnf., t. ii, p. 100) quotes M. Trousseau as making the follow- 
ing remarks: " For sixteen years we have not met with a single child 
who has presented any verminous symptoms; never or almost never does 
a child born and reared in Paris discharge worms, while just the con- 
trary is true as to the provinces Young children, to be sure, are 

sometimes met with in our hospitals, w^ho discharge worms, but they 
are those who have been born in the country, and have lived in the 
capital only for a short time." Dr. Condie (D/s. of Child., 2d ed., p. 
226), remarks: " Worms are a very common occurrence in the intestines 
of children, and may unquestionably, under certain circumstances, be- 
come a cause of severe irritation; but much less frequently than is 
generally supposed." 

We believe we may conclude, therefore, that though these parasites 
are of very common occurrence, and productive of grave disorders in 
some countries, they are rarely met with in quantities sufficient to do 
serious injury to the health, in other places, as for instance, Paris, and 
probably in this country, or at least in the northern parts of it. 

That intestinal w^orms do, however, not unfrequently in some coun- 
tries, and occasionally in all, produce dangerous and even fatal disturb- 
ances of the health, cannot be doubted after careful perusal of the evi- 
dence brought forward by diff'erent authorities. M. Guersant, amongst 
others, remarks (loc. cit., p. 670) : " It is nevertheless incontestable, 
that the development of these animals in the gastro-intestinal and ab- 
dominal cavities, does sometimes give rise to very varied morbid phe- 
nomena, which are in some instances grave enough to cause death." 
Kevertheless, we are disposed to believe, as stated above, that fatal, or 
even dangerous results from the existence of these parasites, are of rare 
occurrence in this city, and probably throughout our Northern States. 
Dr. Dewees, how^ever, mentions several cases in w^hich they produced 
alarming symptoms, and one in particular (Dis. of Child., p. 492), in 
which the subject, a child twenty months old, was extremely emaci- 
ated, and whose abdomen was "enormously distended, and semi-trans- 
parent," who recovered rapidly after ninety-six lumbricoides, from six 
to ten inches long each, had been expelled under the use of pink-root 
in infusion. 



ASCARIS LUMBRICOIDES. 965 



ARTICLE I. 



ASCARIS LUMBRICOIDES. 



The description of this worm has already been given at page 961. 

Causes. — Under this head we shall not pretend to consider the ques- 
tion of the origin of worms, but only the causes which predispose to 
their production, or favor their growth. 

Age has no doubt a considerable influence upon the predisposition to 
lumbricoides. According to M. Guersant (he. cit., p. 685), infants at 
the breast under six months of age are very rarely affected with them. 
Instances occasionally occur, but are altogether exceptions to the gen- 
eral rule. Above six months of age, they begin to be met with, but 
still very rarely, so that scarcely one or two Avill be found in several 
hundred children of a very early age; while from three to ten years of 
age they will be observed in about a twentieth, or in some seasons per- 
haps in a larger proportion. M. Yalleix states that he has never met 
with them in new-born children. Dr. Dewees says {loc. cit., p. 481), 
that he has never seen worms in children under ten months old; and in 
onl}^ two instances at that age. We do not recollect ourselves ever to 
have seen them in subjects younger than eighteen months, and very 
rarely in those under three or four years. 

There can be little doubt that the disposition to worms is hereditary 
in some families. It is generally believed that the species under con- 
sideration is more common in girls than boys; that it is most common 
in children of lym2)hatic and scrofulous constitutions; and that a too ex- 
clusively vegetable or milk diet, and an abuse of fruits, strongly predis- 
pose to their production. The habitation of a cold and damp, or w^arm 
and damp climate, and the seasons of summer and autumn, are sup- 
posed by many also to favor their production and growth. It is a gen- 
eral belief, and we should suppose from personal experience, a well- 
founded one, that a feeble and disordered state of the digestive function 
from any cause, often acts as a predisposing cause of worms, and par- 
ticularly of lumbricoides. 

Seats. — The small intestine is, in a very large majority of the cases, 
the scat of the ascaris lumbricoides. They are met with, however, in 
other parts of the digestive tube, particularly the stomach and large 
intestine, and more rarely in the oesophagus or pharynx. In some in- 
stances they are found to have migrated to other organs, as to the 
liver, gall-bladder, and in still rarer eases they have passed into the 
peritoneal cavity, bladder, lar^-nx, trachea, bronchia, and even into the 
nasal passages and frontal sinuses. They have also been met with oc- 
casionally in the walls of the abdomen, forming verminous abscesses, 
whence they have escaped on the opening of the abscess. 

The number of ascarides is exceedinglj^ variable; there may be onl}- 
two or three, ten or twenty, or several hundred. When very numer- 



966 ASCARIS LUMBRICOIDES. 

ous, they are apt to be rolled or twisted into knots or balls, which have 
been seen as large as the fist, so as to block up completely the canal of 
the intestine. In a case cited by Eilliet and Barthez, from M. Daquin, 
the duodenum was so filled with worms as to be distended, and to have 
acquired a considerably larger size than natural, while at the same 
time it was hard and elastic. The jejunum, ileum, and caecum w^ere 
filled, so that it seemed as though the worms must have been pushed 
in by force. They w^ere found also, but in smaller quantity, in the 
colon. Dr. Condie (loc. cif., p. 230) states that he has known one hun- 
dred and twenty lumbricoides to be voided in a single day by a child 
five years old. It ought, however, to be remarked, that the instances 
in which such large numbers are met with are altogether exceptional, 
especially in our Northern States. We have never ourselves known 
more than six, eight, or ten to be expelled within a few days' time, and 
very generally there have not been more than three, four, or five. 

Anatomical Lesions. — When the number of lumbricoides is small, 
the mucous membrane has been found in a state of perfect health, while, 
on the contrary, when they are numerous, and especialh^ when col- 
lected together into knots, the membrane has presented a fine injection 
like that which exists in erythematous enteritis; in some very rare in- 
stances on record, in which the quantity of worms has been very great, 
the mucous membrane has been found deeply injected, thickened, granu- 
lated, and, in a smaller proportion of cases, softened, and even eroded. 
Not unfrequently the intestine presents all the characters of well- 
marked enteritis, or entero-colitis. though the number of worms may 
be very small. In such cases, it is reasonable to suppose that the in- 
flammatory affection has been an accidental complication of the ver- 
minous disorder. 

Much discussion has arisen in regard to the manner in w^hich perfora- 
tion of the intestine, as an accompaniment of worms, takes place. It 
is necessary to suj^pose, in subjects in whom w^orms are found in the 
peritoneal cavity, or in abscesses formed in the abdominal parietes, that 
perforation of the bow^el has taken place, and yet in some instances no 
trace of the opening is left, no inflammation of the serous membrane 
is met with, nor has there been any escape of the contents of the di- 
gestive canal into the abdominal cavity. In others, however, and much 
the most numerous cases, it is evident from the anatomical appearances, 
that the perforation has taken place in consequence of previous ulcer- 
ation of the coats of the bowel, and that the worms have escaped with 
the other contents of the intestine. It is in regard to the former class, 
therefore, that discussion has principally taken place; some asserting 
that the parasite itself makes the opening, by an active process, while 
others deny the possibility of this occurrence, and maintain a previous 
ulceration or softening in all cases. Amongst those who advocate the 
possibility of perforation independent of previous change in the intes- 
tinal coats by disease, are MM. Mondiere and Charcelay, the former of 
whom has examined the subject with a great deal of care, quoted by 
Rilliet and Barthez ; Eilliet and Barthez themselves; the authors of 



ANATOMICAL LESIONS — SYMPTOMS. 967 

the Bihlioth. du Med. Prat., and M. Guersant; while amongst those op- 
posed to this opinion may be cited, MM. Cruveilhier, Barrier, Dr. Ar- 
thur Farre, who greath^ doubts the possibility of the accident, and Dr. 
Condie. We confess ourselves inclined to believe, from facts stated by 
different authors, and from the history of two cases which occurred to 
M. Guersant in 1841, at the Children's Hospital of Paris (loc. cit., p. 
680), that worms may in some instances cause a perforation indepen- 
dently of previous disease of the coats of the intestine. In one of these, 
two lumbrici were found engaged in an opening in the appendix vermi- 
formis, half the bodies of the animals being in the appendix, and half 
in the peritoneal sac; while in the other, an opening of the same kind 
as in the previous case was found in the appendix, and though the three 
worms which were found lying in the abdominal cavitj^, might have 
escaped through an ulcerated perforation of the colon, it is not the less 
true that the opening in the appendix presented the same characters 
exactly as in the first case, in which the animals were, as the author 
remarks, "taken in the act." In both instances, the perforation of the 
appendix was at the extremity of that canal, and in the form of a nar- 
row opening of a conical shape; the membranes were smooth, thinned, 
and the edges of the orifice sloped off from within outwards; no trace 
of anterior ulceration Avas perceptible. 

In regard to the verminous abscesses already referred to, we shall make 
but few remarks, referring the reader to more extensive treatises for 
fuller information. These abscesses have been, in very rare instances, 
met with in the pharynx and nasal passages, but much more frequently 
they exist in the abdomen. The latter may be of two kinds, stercora- 
ceous and non-stercoraceous. In the former, the abscess, which forms 
upon some portion of the walls of the abdomen, gives issue not only to 
the worm or worms, and pus, but also to fecal and even alimentary sub- 
stances, and leaves behind a fistula connecting with the cavity of the 
intestine, which may cicatrize after a short time, or remain open during 
life. In the other form of abscess, the opening through the coats of 
the intestine has been closed immediately after the passage of the worm, 
so that the abscess gives issue only to the animal and pus, after which 
it heals up without giving rise to a fistula. 

The verminous ab.^cesses are said to be found generally about the in- 
guinal and umbilical regions; to occur most frequently between the 
ages of seven and fourteen years, and not to be, as a general rule, very 
dangerous to life. 

Symptoms Indicative of the Presence of Worms. — We believe it is 
almost universally acknowledged b}' later writers, that there is no single 
symptom, nor group of symptoms, other than the expulsion of the worms, 
and their detection, which indicate with certainty their existence in 
the digestive tube. This is the expressed opinion, amongst others, of 
MM. Guersant, Eilliet and Barthez, Barrier, Yalleix, and Drs. Eberle 
and Condie, and it is also the opinion which we have ourselves been led 
to form from our experience amongst children. 

Another point worthy of remark is, that even though one or several 



968 ASCARIS LUMBRICOIDES. 

worms may have been expelled, it is not always fair to conclude that 
the symptoms under which the child labors, are the result of the pres- 
ence of others of these animals, as there may be no more in the bowels, 
or they may be so few in number as not to produce injurious effects; 
while, on the contrary, various disorders of the digestive tube, as chronic 
indigestion, simple diarrhoea, and inflammatory diseases of the gastro- 
intestinal mucous membrane, may and do exist simultaneously with, 
and yet independently of, the presence of these parasites. 

The symptoms generally enumerated as indicative of the presence of 
worms are the following. The child presents various signs of disturbed 
health. The stomach is more or less deranged, as shown by furred 
tongue, eructations, variable appetite, which is sometimes diminished, 
and sometimes in(;reased, thirst, acid or heavy breath, and nausea. The 
abdomen may be enlarged or retracted, generally the former, and is 
often more or less hard and painful to the touch ; the condition of the 
bowels varies in different cases, as they are sometimes costive, and some- 
times affected with diarrhoea. According to M. Guersant, the stools 
often contain glairy substances, and are sometimes streaked with blood 
and of a yellowish-green color; the patient often suffers from colics, 
which may be either dull or acute, though more generally the latter, 
and which are generally felt at the umbilical region. Children affected 
with lumbricoides are said to present a peculiar physiognomy ; the face 
is usual 1}^ paler than natural, and sometimes has a leaden tint; the aye^ 
are surrounded by bluish rings, and have at the same time a dull and 
languid expression; the inferior eyelids are often swelled and puffy; 
the sclerotic coat of the eye assumes a bilious tint; the nostrils are 
said to be sometimes swelled, and the child complains much of irritation 
and itching of those parts, and is constantly picking at them with the 
fingers. In some instances epistaxis takes place. The child is gener- 
ally pale and thin, indolent and languid, or irritable and unhappy. The 
sleej) is almost always disturbed. This indeed is, it seems to us, one of 
the most important signs both of worms and of chronic functional dis- 
orders of the stomach and bov/els. The nights are almost alwaj'S rest- 
less, the patient either waking often to drink, or waking in fright and 
alarm fi-om dreams, or else constantl}' tossing and turning in sleep, 
moaning, or grinding the teeth. 

Other symptoms mentioned b}' different observers, and by some very 
much depended upon, are acceleration with irregularity of the palse, and 
dilatation, especially unequal dilatation, of the pupils. We might cite 
also strabismus, and occasionally cough. 

Jn children in whom the number of lumbricoides is very large, the 
constitution suffers to a dangerous degree. The s^^mptoms above enu- 
merated are vtrj marked, and at the same time the child is very pale 
or sallow, emaciated, weak, and without appetite; the abdomen is hard 
and tumid; the nervous s3'mptoms are severe, and some of the sj'mp- 
toms which we shall describe ])resently, under the head of disorders 
occasioned by worms, are also observed. 

It should be remarked, however, again, that all or any of the symp- 



MECHANICAL EFFECTS. 969 

toms just described ma}^ exist independently of the presence of worms, 
the only certain sign of which is their expulsion from the patient. 

Morbid Effects occasioned by Worms. — MM. Eilliet and Barthez 
divide the accidents or effects produced by the existence of lumbricoides 
into two groups: those which result from the mechanical influence of 
the entozoa, as their accumulation or displacement; and those which 
appear to be the consequences of a purely sympathetic action on the 
different systems of the bod}", and particularly the nervous system. 

Mechanical Effects. — Under this head are included perforation and 
hemorrhage of the intestine, enteritis, abscesses, and the symptoms de- 
termined by the displacement or migration of the worms into the ductus 
communis choledochus, the liver, or the air-passages. 

Of perforation and abscesses, we have already treated under the head 
of anatomical lesions. Hemorrhage is a very rare event, but it occurred 
in one instance cited by MM. Eilliet and Barthez, and Guersant, from 
M. Charcelay, in consequence of the rupture of an arteriole in a small 
rounded ulceration in the duodenum, apparently occasioned by the pres- 
ence of a large number of lumbrici. Enteritis, as an effect of the pres- 
ence of worms, has also been referred to under the head of the ana- 
tomical lesions. In many instances it is, no doubt, a mere accidental 
complication, in no way connected with the presence of entozoa; prob- 
abl}" this is true of a large majority of the cases. When, however, the 
number of the parasites is very great, and particularly when they arc 
collected into large or firm knots and bundles, they mny, no doubt, 
occasion, by their mechanical irritation, inflammation, thickening, soft- 
ening, and even destruction of the raucous tissue, as in cases cited by 
M. Guorsant, from MM. Bretonneau and Charcelay, and in one which 
occurred to himself. It should bo remarked^ however, that the cases 
on record in which ulcerations evidently dej^ended upon the presence 
of worms, are, so to speak, infinitely few in comparison with those in 
which no such alteration existed, or in which it was evidently independ- 
ent of any influence exerted by the worms. 

Effects caused by the Displacement or Migration op Worms. — 
Lumbricoides have been found, as we have already seen, in the walls of 
the abdomen, giving rise to abscesses. They have been discovered, also, 
in the vcrraifbrm appendix, in the ductus communis choledochus, in the 
gall-bladder, in the hepatic ducts in the substance of the liver, forming 
abscesses, and in the pancreatic canal. The symptoms occasioned by the 
latter class of cases are very obscure. In one instance, M. Guersant 
supposed that an attack of convulsions depended upon the presence of 
worms in the common duct. 

More numerous examples are on record, in which violent dyspnoea 
and cough, and fatal asphyxia, have occurred in consequence of the 
pressure of lumbricoides which had passed into the oesophagus, or from 
their introduction into the larynx, trachea, or bronchia. The symp- 
toms occasioned by these accidents are a sudden attack of dyspnoea, 
anxiet}', agitation, threatened suffocation, dry, spasmodic cough, acute 
painful cries, pain in the larynx or trachea, and, unless relief be obtained 



970 ASCARIS LUMBRICOIDES. 

in a few hours, death. This kind of attack may depend on the rising 
of a worm or bundle of worms into the oesophagus, causing pressure on 
the larynx and trachea, as in the case reported by M. Tonnelle, in which 
the sj-mptoms disappeared after the expulsion of a large number of 
worms. One of us has met with an instance of this kind. It occurred 
in a boy fifteen years old, presenting every mark of strong and vigor- 
ous health, but who, for three or four weeks before we were consulted 
in regard to him, had been subject to sudden and apparently causeless 
attacks of suffocation, which seized him without the least warning. 
When the attack came on, he would for some instants cease to breathe, 
or breathe with much difficulty. He always seemed to suffer from the 
greatest anxiety; the countenance became altered and distressed; he was 
unable to speak, but made signs for water, and when able to swallow a 
mouthful, which was always exceedingly difficult, was at once relieved. 
His mother told us that he always appeared to be in the greatest dis- 
tress, so that, on several occasions, she feared for his life. Striking him 
violently on the back, which she, when present, always did, sometimes 
relieved him, but generally the difficulty continued until he could swal- 
low a little fluid of some kind. These attacks were unattended at the 
time b}' cough, nor was there the least sign of disorder of the respira- 
tory sj'stem in the intervals between them. Suspecting that the diffi- 
culty must depend on the rising of a worm or worms into the oesophagus, 
or upon sj-mpathetic irritation from the presence of these parasites in 
the stomach, and learning that he had been troubled with worms some 
years previously, we gave him wormseed oil, which caused the expul- 
sion of a few large lumbricoides, after which he had no return of the 
symptoms. 

The attacks of dyspn-oea may depend also, as already stated, on the 
introduction of worms into the air-passages. Under these circumstances 
death is very apt to be the result. In one instance, however, reported 
by M. Arronsshon, after the difficulty had lasted two hours, tiie patient, 
a little girl eight years old, after violent efforts at coughing, threw up 
a living lumbricus. 

We have next to consider the sympathetic effects, and particularly the 
nervous symptoms, occasioned by worms. We may include amongst the 
nervous symptoms produced by worms the headache, languor, irrita- 
bilitj-, restless and disturbed sleep, and grinding of the teeth, so fre- 
quently observed. These, however, are of but slight importance in 
comparison with certain other disorders of the nervous system, which 
do undoubtedly^ occur sometimes^ though we should suppose very rarely, 
in proportion to the whole number of subjects affected with the para- 
sites. The disorders to which we allude are partial or general convul- 
sions, chorea, hysteria, and catalepsy, which are the most frequent, 
though, as so often stated already, extremely rare in comparison with 
the number of cases in which the presence of the worms produces no 
such effects. Other disorders cited by the authors of the Bib. du 
Med. Frat., with cases to prove their reality, are insanity, paralysis, 



DIAGNOSIS — PROGNOSIS. 971 

coma, palpitations, strabismus, cough, hyperajstbesia of tbe skin, amau- 
rosis, and aphonia. 

DiAGNOSis.-^It has already been stated that there are no certain signs 
of the presence of worms in an individual except their expulsion. The 
symptoms which have seemed to us most stronglj^ to indicate their 
presence arc, a chronic disordered state of the digestive apparatus, pro- 
ducing irregular appetite, which is sometimes good and at others bad; 
slight emaciation ; paleness or unhealthy tint of the complexion ; languid 
expression of the face; some irritability of the temper, or a want of the 
gaA'cty and activity of disposition natural to childhood; picking at the 
nose; often some tumidity of the abdomen, which may be at the same 
time either hard or merely tympanitic ; and, what seems to us more im- 
portant than any that we have named, yevy restless and broken sleep 
at night, with frequent grinding of the teeth. 

M. Yalleix remarks that, in a case pi-esenting nervous symptoms 
simulating disease of the brain, we may suspect the existence of worms, 
if we learn upon inquiry that symptoms of marked intestinal disorder, 
the various signs cited above as indicative of the presence of worms, 
and different derangements of digestion, had preceded for some time 
the appearance of the nervous sjnnptoms; chiefly for the reason that, 
in most diseases of the brain, the digestive tube is, at the invasion, in a 
state of integrity, with the exception of sympathetic vomiting. If we 
can learn, upon inquiry, that tiic child has discharged worms on some 
previous occasion, the probability of the dependence of the symptoms 
wpon them becomes still stronger. 

It is sometimes difficult to determine positively whether certain sub- 
stances discharged at stool are fragments of worms, or whether they 
are portions of imperfectly digested aliment, or foreign bodies. The 
thini^s which most resemble lumbricoides, are the remains of tendons, 
ligaments, vessels, fibres of plants, &c. To make the distinction with 
certain t}", the doubtful substance ought to be placed in water, so that 
it may be thoroughly cleansed, after which it must be carefully exam- 
ined as to its structure, arrangement, consistence, &c., with the eye, 
and with the microscope, if necessarj^ M. Guersant has suggested a 
very easy method of ascertaining whether the substance bo animal or 
vegetable, which is to subject it to heat, after it has been carefully 
washed, when the odor will at once inform us of its real nature. 

Prognosis. — It is no doubt a very rare event, at least in the northern 
parts of our country, for life to be endangered by the presence of 
worms. We have never, ourselves, met with an instance in which the 
general health was more than moderately disturbed by this cause. 
That verminous affections are sometimes, however, dangerous to life in 
this city, is shown by three cases related by Dr. Dewees, in which very 
severe and threatening symptoms were instantly relieved upon the ex- 
pulsion of lurabrici after the exhibition of vermifuges. 

Worms become dangerous to life when they migrate from their orig- 
inal seat to neighboring and important organs, particularl}^ the air- 
passages and liver. The prognosis is unfavorable also when- they 



972 ASCARIS LUMBRICOIDES. 

accumulate in veiy large numbers, and give rise to the diiferent nervous 
symptoms above described. 

Treatment. — Before commencing our remarks upon the particular 
remedies emploj'ed for the destruction and expulsion of worms from 
the alimentary canal, we would call the attention of the reader to the 
fact that most of the recognized anthelmintics are more or less irrita- 
ting to the gastro-intestinal mucous membrane, and some of them to 
the nervous system also, producing, in overdoses, severe and even dan- 
gerous nervous symptoms. It is evident, therefore, that remedies of 
this class ought not to be exhibited unless they are manifestlj^ called 
for, and not at all when symptoms of severe gastro-intestinal irritation, 
and particularly of inflammation, are present, unless there be the very 
strongest reasons for supposing that those symptoms depend upon 
accumulations of worms. We are quite sure that we have, in a con- 
siderable number of instances, met with children whose digestive 
organs had been injured, and in whom slight functional derangement 
had been converted into severe indigestion, and even inflammatory dis- 
order, b}^ the too frequent or long-continued use, or the administration 
in excessive quantities, of different vermifuges, and of various quack 
nostrums, which are sold to an amazing extent in this city, and all 
over the country. 

As the diagnosis of worms is always doubtful, it is best never to risk 
the administration of any of the irritating vermifuges, unless convinced, 
by the previous expulsion of worms, that they are almost certainly 
present; and, indeed, we ourselves rarely give any other remedy than 
small quantities of the icormseed oil in slight, and especially in doubtful 
cases, unless this has already been tried and failed. From our own 
experience, we believe that this remedy is all-sufficient in a large ma- 
jority of the cases that occur in this city; as these are almost always 
of a mild character, and, as it not only produces the expulsion of the 
parasites when they exist, but also acts beneficially upon the forms of 
digestive irritation which simulate so closely the symptoms produced 
by worms. We are persuaded, indeed, that of all the cases that have 
come under our notice, in which it seemed probable that worms m.ight 
be present, none were expelled in nearl}" half, and yet the signs of dis- 
turbed health have passed away under the use of the remedy. The oil 
of wormsecd may be given in doses of four drops to children of two 
years of age, and of six or ten to those above that age, three times a 
day for three da3-s, to be followed on the morning of the fourth day by 
a moderately active, but not irritating cathartic dose, the best of which 
is castor-oil or syrup of rhubarb. The objection to the remedy is its 
nauseous taste and smell; these, however, may be partially disguised 
by making it int^ a mixture with yolk of Ggg, powdered gum, and 
syrup of ginger. Some children take it very well dropped upon a lump 
of white sugar, while others take it best mixed with common brown 
sugar. If one course of the oil, as it is called^ fail to relieve the symp- 
toms, another should be administered. It ought to be recollected that, 
when given in large doses, the wormseed oil is irritating to the diges- 



TREATMENT. 973 

tive mucous membrane, and produces dangerous nervous symptoms. 
We know of one case, in Avhich a girl six or seven years of age was 
made exceedingly ill, and suffered for j'ears afterwards, from the effects 
of a teaspoonful of the oil given by mistake. The following is a very 
good formula for the administration of this remedy : 

R. — 01. Chenopodii, gtt. Ix vel f^j. 

P. G. Acacise, ...... ^ij. 

Syrup. Simp., f^j. 

Aq. Cinnamom , f^ij. — M. 

Give a dessertspoonful three times a day, for three days, and repeat after several 
days. 

The wormseed may be given also in powder, in the dose of from 
twenty to forty grains. 

The remedies most frequently employed in this country besides the 
wormseed, are pink-root or sjoigelia, oil of turpentine, calomel, and the 
bristles of cowhage. 

We believe that the pink-root is more depended upon amongst us than 
any other single remedy. It is given either in substance or infusion. 
The dose of the powder is from ten to twenty grains for a child three 
or four years old, to be repeated every morning and evening for several 
days, and followed by an active cathartic. The powder is seldom used, 
however, as the drug is almost always given in infusion. The best and 
safest mode of administering it is in combination with cathartic sub- 
stances. Thus, half an ounce each of pink-root and senna may be in- 
fused for a few hours in a pint of boiling water, and a tablespoonful 
given two or three times a day to children two or three years old, for 
three, four, or five days, when it should be suspended for a time, and 
resumed, if necessary. A preparation much used in this city under the 
title of w^orm-tea, and which we have ourselves given with very good 
success, consists of the spigelia mixed with senna, manna, and savine, 
in different proportions, made into an infusion and sweetened with 
brown sugar. Dr. Gr. B. Wood (Fract. of Med., vol. i, p. 626) recom- 
mends the following formula : 

R. 



Sennse, Spigelise, . 


aa gss 


Magnesige Sulphat., 


. . 3^J- 


Mannse, 


. . . IJ. 


Fceniculi, 


. 5J- 


Aquse Fervent., 


. . . Oj. 



These are to be macerated for two hours in a covered vessel, and a 
tablespoonful given to a child two years old once or twice a day, or 
every other day, so as to procure two or three evacuations in the 
twenty-four hours. The remedy is continued for a few days, or for one 
or two weeks, if necessary, and if it do not debilitate the child. 

The fluid extract of spigelia and senna has been introduced as a more 
convenient and acceptable mode of adm'nisl:ering this vermifuge with 
a cathartic. The dose for a child is from thirty minims to a teaspoon- 
ful, according to the age. 



974 ASCARIS LUMBRICOIDES. 

The spirit of turpentine is highly recommended as an efficient remedy 
for worms by several authorities, and particularly by Dr. Joseph Kh\pp 
and Dr. Condie, of this city. Dr. Condie states that it is the article 
from which he has derived the most decidedly beneficial effects, and 
remarks that it may be given when there exists considerable irritation 
of the alimentary canal, or even subacute inflammation, without any 
fear of its increasing either. He gives the rectified spirit in sweetened 
milk, in molasses, or in the following mixture: 

R.— Mucil. G-. Acaciffi, f^ij. 

Sacch.Alb., ^x. 

Spir. ^ther. Nitr., f^iij- 

01. Terebinth., f^iij- 

Magnes. Calcinat., 9J- 

Aqu83 Menthae, f^j. — M. 

Of this mixture a dessertspoonful is given every three hours. 

We have used the spirit of turpentine but seldom, on account of its ex- 
tremely disagreeable taste, having always succeeded perfectly well with 
the wormseed oil, or with infusion of pink-root with cathartics. 

Calomel also is highly thought of by many persons as a vermifuge, 
and, no doubt, when used in combination with or followed by cathar- 
tics, or given in full purgative doses, it is very effectual. We can only 
repeat what we have already said on several occasions, that it is a 
remedy which, from the powerful influence it exerts upon the consti- 
tution, ought not to be given except when really called for; and, as we 
can almost always succeed in curing verminous affections by milder 
drugs, we see no occasion for resorting to this, except in rare cases. 
When used it is given alone in considerable doses, and followed by 
some cathartic, or in combination with rhubarb and jalap, or jalap, or 
scammony. 

The bristles or down of cowliage are also used by some practitioners, 
no doubt sometimes with success. We have never used them, and can 
give no opinion, therefore, from personal experience, as to their effi- 
cacy. They are administered b}^ making them into an electuary with 
honey, sj^'up, or molasses, a teaspoonful of which is given every morn- 
ing for three days, and then followed by an active cathartic. 

The following electuary^ recommended by Bremser, is very much em- 
ployed in Europe, and is highly spoken of by Dr. Eberle : 

R. — Semin. Santonicse (semen-contra of the French writers), 

Semin. Tanaceti rude contus., .... aa Jss. 
Valerian, pulv., ........ ^^ij. 

Jalapse pulv., 3Jss.-ij. 

Potass. Sulphat., ^jss.-ij. 

Oxymel. Scillse, q. s. — ut ft. 

Electuarium. 

A teaspoonful of this is given morning and evening for three or four 
days, when the dejections generally become more copious and liquid. 
If it do not produce this effect, Bremser advises that the dose be in- 



TREATMENT. 975 

creased. Dr. Eberle gave it for six or seven days, and says it does far 
less good when it produces frequent and watery evacuations, than 
when it causes only three or four consistent stools a day. This 2:>i'epara- 
tion has a very disagreeable taste, and children sometimes refuse to take' 
it on that account. When this is the case it may be made into pills. 

M^I. Eilliet and Barthez recommend the following syrup, which was 
proposed and highly thought of by M. Cruveilhier: 

J^. — Follicul. Sennte, Khei, Semin. Santonic, Artem. Abrotan., 

Helminthocort., Tanaceti, Artemis. Pontic, . . . aa 5]. 
To be infused in half a pint of cold water, strained, and made into a sj^rup with 
sugar, of which a tablespoonful is to be given every morning for three days. 

M. Cruveilhier states that this sj'rup has been very successful in his 
hands. Of late years, santonin, the active principle derived from the 
European wormseed, has been much employed, and with very good 
success. The remedy may be given in doses of from gr. ij to gr. v, 
combined or followed by a dose of castor-oil or senna. The empyreu- 
matic oil of Chabert is also highl}^ spoken of by some European authori- 
ties. It is made by mixing one part of the empyreumatic oil or fetid 
spirit of hartshorn, with three parts of spirit of turpentine, and allow- 
ing them to digest for four days. The mixture is then put into a glass 
retort and distilled in a sand-bath until three-fourths of the whole have 
passed over into the receiver. The product should be kept in small 
and tightly-closed vials. The dose is about fifteen or twenty drops 
three or four times a day, for children between two and seven years 
old. This is recommended highly by Bremser and other authorities. 
The great objection to it is its exceedingly nauseous taste. Dr. Eberle 
speaks in very favorable terms of a strong decoction of hehninthocorton 
or Corsican moss, which he has found "not only valuable as a vermi- 
fuge, but particularly so as a corrective of that deranged and debilitated 
condition of the alimentary canal favoring the production of worms." 
An ounce of helminthocorton, with a drachm of valerian, are to be 
boiled in a pint of water down to a gill, and a teaspoonful of the decoc- 
tion given morning, noon, and evening. It is particularly beneficial in 
cases attended with the usual symptoms of worms, connected with 
want of appetite and mucous diarrhoea, and arising from debility of the 
digestive organs, and a vitiated condition of the intestinal secretions. 

Kameela, the reddish-brown powder which clothes the capsules of 
the Rottlera tinctoria, has been of late highly recommended, not only 
in cases of taenia, but of ascaris lumbricoides. 

The dose for children is about gr. v, repeated till it has acted on the 
bowels. 

In all cases of deranged health supposed, either from the nature of 
the symptoms, or proved by the previous expulsion of worms, to de- 
pend on the presence of these animals in the alimentary canal, it is ex- 
ceedingly important to attend to the hygienic treatment of the child, and 
in some instances to administer tonics and stimulants. In not a few cases 
that have come under our own notice, in which man}" of the sj'mptoms 



976 ASCARIS LUMBRICOIDES. 

supposed to indicate the presence of worms have been extremely well- 
marked, we have succeeded in removing them all without a resort to 
any vermifuge, by the treatment proper for the chronic indigestion or 
dj'spepsia of children. The method of treatment to be employed in 
such cases has already been laid down in the article on indigestion, to 
which the reader is referred for full information. It should consist 
chiefly in strict attention to exercise and diet, and in the use of tonics, 
as quinia and iron, and small quantities of fine port wine. 

Whenever any complication exists in connection with worms, the 
treatment must be modified according to its nature. If it consist in 
inflammation of any part of the digestive tube, the inflammation ought 
to be attended to first, and the verminous disorder for the time neg- 
lected. If the inflammation be very slight, or if the sj'mptoms indi- 
cate only severe irritation rather than positive inflammatory action, we 
may exhibit the milder and least injurious vermifuges, as vcr}^ small 
doses of wormseed oil, which we have never known to do harm, the de- 
coction of helminthocorton and valerian, recommended by Dr. Eberle, 
or, according to Dr. Condie, the spirit of turpentine. If the verminous 
affection coexist with any of the acute local inflammations of the thorax, 
the former ought to be, as a general rule, neglected, until the latter has 
been relieved by appropriate treatment. In doubtful cases, in which it 
is impossible to ascertain with certainty whether the symptoms depend 
on w^orms, or upon a simple dyspeptic condition of the digestive organs, 
it is most prudent to give only the simplest and least irritating vermi- 
fuges, to regulate the hj^gienic conditions of the patient, and afterwards 
to resort to tonics, if necessary. 

Various writers, and particularly M. Guersant, advise that we should 
forbid, in verminous cases, the use of relaxing food, especiall}^ of milk 
preparations, fruits, and of fatty and farinaceous substances; and that, 
after the expulsion of the worms, we should direct a tonic and strength- 
ening regimen. The diet should consist of boiled and roasted meats, of 
wine, and of bitters. The author just quoted, states that a change of 
food alone will often suffice to procure the expulsion of w^orms. He 
says {Diet, de Med.,t. xxx, p. 689), "I have met with children who had 
been tormented with ascarides lumbricoides while residing in the coun- 
try and living upon milk and fruits, and who, upon being brought to 
the city, and put upon the use of broths and soups, passed considerable 
quantities of worms, and after that got entirely rid of them." 

Occasionally our opinion is asked with reference to worms of other 
varieties, which are reported to have been passed from the rectum of 
children. Thus, tapering elongated pieces of coagulated casein maybe 
mistaken for worms. 

So, too, w^e have seen a specimen, submitted to us by Dr. Bussey, of 
Buena Yista, Texas, and said to have been passed by a boy there, of 
male Gordicus aquaticus, or horse-hair worm. This is a nematoid 
worm, of chestnut-brown color, a foot in length, a little more than one- 
half line in breadth, with a bifid caudal extremity. It grows in stagnant 
water, and thus may readily have been swallowed and passed per anum. 



ASCARIS VERMICULARIS. 977 

AETICLE II. 

ASCARIS VERMICULARIS. 

The description of this worm has already been given at page 962. 

Seat. — The ascaris vermicnlaris is found almost exclusively in the 
large intestine, and in a large majority of the cases is confined to the 
rectum. It is said to have been found in the vagina in the female, 
having no doubt passed from the rectum into that canal. 

The causes which determine the presence of this worm are not at all 
understood. 

Symptoms. — The characteristic, and often the only symyjtom indica- 
tive of their presence, is violent itching about the anus, which is some- 
times almost insupportable, and which is generall}^ most troublesome 
and most apt to occur at night when the child is in bed. In some in- 
stances they give rise to acute and violent pain in the region of the anus, 
and sometimes to tenesmus and mucous or bloody stools. When the 
last-named severe symptoms exist, the worms may occasion dangerous 
nervous disorders, and even give rise to general convulsions. The worms 
not unfrequently escape from the rectum and are found upon the bed- 
clothes, or upon the clothes which the cliild lias worn through the day. 
Sometimes they are discharged in considerable numbers, and are found 
in that case, either mixed with the faeces, or with mucus, or collected 
into balls ot knots. 

The diagnosis of the seat-worm, like that of the lumbricoides, cannot 
be regarded as positive, unless some have been expelled, or unless they 
can be seen by examination of the rectum. This can generally be done 
when they are present in any number, by pressing the nates apart so 
as to open the anus and bring the folds of the mucous coat of the bowel 
into view. The only other symptom which indicates their j)resence 
with any certainty, is the existence of severe itching about the anus, 
not to be explained upon any more reasonable supposition. 

Prognosis. — These worms do not, as a general rule, produce the same 
disturbances of the general health as lumbricoides, and in not a few 
instances are entirely innocuous, with the exception of the pain and 
inconvenience they occasion. 

They are, however, exceedingly troublesome, because of the difficulty 
of removing them entirely by any treatment. J^o matter how many 
are discharged, some almost always remain concealed in the folds of 
the mucous membrane, and as the}' are propagated with great rapid- 
ity, the same train of symptoms is very apt to return soon after they 
may have been seemingly dislodged. 

Treatment. — It has been found by long experience that the com- 
mon vermifuges, given by the mouth, exert much less influence in caus- 
ing the expulsion of these worms than of the lumbricoides. For this 
reason enemata are generally resorted to in the treatment, instead of 

62 



978 ASCARIS YERMICULARIS. 

remedies given by the moutb. Dr. Dewees, however, recommends the 
elixir proprietatis (tinct. aloes et mjn'rhje), in small and often-repeated, 
doses, continued for some time, and followed by enemata of lime-water, 
camphor, or aloes. He gave twenty drops of the elixir three times a 
day, in a little sweetened milk, to children from two to four 3'ears old, 
and thirty drops to those between five and seven years. 

The plan we have generally resorted to has been to give small doses 
of the wormseed oil, as directed in the article on lumbricoides, and to 
direct an injection of from four to six grains of powdered aloes, sus- 
pended in a gill of warm milk, for children four years old, to be re- 
peated once in three, four, or five days, according to the necessity of 
the case. 

Lime-water by injection is recommended by several different author- 
ities. It may be given of its ordinary strength, or mixed with an 
equal quantity of warm milk, or flaxseed mucilage. Other enemata 
recommended are spirit of turpentine in milk, a teaspoonful of the for- 
mer to a gill of the latter ; decoction of helminthocorton; an injection 
made by infusing two drachms of fresh garlic-cloves in three ounces 
and a half of boiling water, and adding to the infusion, after it has 
been poured off, a scruple of assafoetida rubbed up with the yolk of an 
Ggg', a- solution of from six to twelve grains of sulphuret of potassium 
in half a pint of water ; injections of sweet oil, or of lard beaten up with 
water until it becomes fluid, and even of cold water. Tlje three last- 
mentioned substances have the advantage of calming the itching and 
irritation of the rectum almost immediately. Enemata of a solution of 
nitrate of silver, in the proportion of two to four grains to the ounce 
of water, have been recommended by Schultz (Deutsche Xlinik, quoted 
in 3fed. Times and Gaz., 1858), who asserts that two, or at most three, 
of these injections suflice to effect a cure. Again, it has been recom- 
mended to pass a bougie smeared with mercurial ointment into the 
rectum. We should much prefer a method of using this ointment 
which succeeded in the hands of M. Cruveilhier in a very severe case. 
This was to place a little of the ointment on the anus, by which course 
the patient was entirely relieved after a few days. In a very obstinate 
case in an adult, Ave succeeded in entirely destroying the worms b}^ the 
daily use of suppositories, made unusually long, and impregnated with 
carbolic acid. M. Valleix states that he has obtained the same results 
by causing the anus to be anointed with the following preparation, a 
small quantity of which was introduced at the same time into the in- 
ferior extremity of the intestine: 

R.— Hvdrarg. Chlor. Mitis, . . . • Biv. 

Axung., 3^^.— M. 

Dr. Wood states that a dose of sulphur taken every morning before 
breakfast has been found very useful. 

The diet and general health ought always to be strictly inquired after, 
and attended to by the phj'sician. For information upon these points 
the reader is referred to the remarks upon hygienic treatment in the 
last article. 



INDEX. 



Abdomen, examination of, and signs from, 46, 
47 
condition of in entero-coHtis, 400, 402 
in cholera infantum, 4ol 
in tuberculous peritonitis, 852 
in tuberculosis of mesenteric glands, 

853 
in variola, 788 
in typhoid fever, 824. 828 
in cases of worms, 968 
Abscess of leg simulating rheumatism, 32 
of lung following pneumonia, 165 
bronchial, in bronchitis, 201 
retro-pharyngeal, 354 
iliac, in disease of coecum and appendix, 

449, 453 
following erysipelas, 886 
verminous, 967 
Absorbents in entero-colitis. 410 
Acarus scabiei, description of 920 
Achorion Schoenleinii, the fungus of favus, 939 
Acids in local treatment of gangrene of the 
mouth, 318 
carbolic, in gangrene of the mouth, 319 
in diphtheria, 680 
in scabies, 923 
in favus, 948 
muriatic, in gangrene of the mouth, 318 
in diphtheria, 679 
in typhoid fever, 834 
sulphuric, in chronic entero-colitis, 419 
^gophony in pleurisy, 235 
Affusion, cold, in scarlatina, 742 

warm, in mild cases of scarlatina, 739 
Air, as injection in intussusception, 476 
Albuminoid degeneration of viscera in scrofula, 

839 
Albuminuria, in pneumonia, 181 
in diphtheria, 668. 672 
during desquamation in scarlatina, 705 
in scarlatinous dropsy, 726 
in variola, 789 
in typhoid fever, 831 
in scrofula, 839 
Alkalies in membranous croup, 103 
in thrush, 342 
in rheumatism, 649 
local use of in diphtheria, 681 
in skin diseases, 947, 951 

Alopecia Areata. 
article on, 954 
frequency of, 954 

fungous nature of, doubtful, 940, 954 
contagion as cause of, 954 
symptoms of, 954 
condition of hairs in, 954 
baldness following, 955 



Alopecia areata, diagnosis of, 955 

prognosis in, 955 

treatment of, 955 
Alum, as an emetic in true croup, 101 

in hooping-cough, 274 
Amaurosis, after diphtheria, 675 

Anesthetics. 

use of during tracheotomy, 122 
in eclampsia, 554 
in tetanus, 589 
Analysis of cow's milk, 337 
of human milk, 340 
of fluid in hydrocephalus, 529 
of bones in rickets, 866 
of fluid in sclerema, 958 

Anatomical Lesions. 
in coryza, 53 

in simple spasmodic laryngitis, 71 
in pseudo-membranous laryngitis, 90 
in congenital atelectasis, 135 
in collapse of the lung, 146 
in pneumonia, 1 63 
in bronchitis, 199 
in emphysema, 220 
in pleurisy, 234 
in pneumothorax, 254 
in hooping-cough, 269 
in cyanosis, 282 
in acute pericarditis, 292 

endocarditis, 293 
in chronic valvular diseases, 294 
in gangrene of the mouth, 310 
in thrush, 338 

in chronic enlargement of tonsils, 346 
in simple pharyngitis, 349 
in simple diarrhoea, 369 
in gastritis, 379 
in entero-colitis, 391 
in cholera infantum, 425 
in dysentery, 443 

in diseases of coecum and appendix, 452 
in intussusception, 463 
in tubercular meningitis, 481 
in simple meningitis, 508 
in cerebral hemorrhage, 520 
in chronic hydrocephalus, 528 
in eclampsia, 547 
in laryngismus, 560 
in tetanus nascentium, 585 
in chorea, 595 

in atrophic infantile paralysis, 623 
in progressive paralysis, with apparent 

hypertrophy of muscles, 643 
in diphtheria, 657 
in mumps, 686 
in rickets, 866 



980 



INDEX. 



Anatomical lesions in albuminoid degenera- 
tion of viscera. 840 
in bronchial phthisis, 843 
in pulmonary phthisis, 843 
in tuberculous peritonitis. 844 
in tuberculosis of mesenteric glands, 846 
in congenital syphilis, 874 
in scarlatinous dropsy, 723 
in scarlatina. 729 
in measles. 772 
in typhoid fever, 823 
in sclerema, 958 
in ascaris lumbricoides, 966 

Anderson McCall. 

on parasitic skin diseases, 940 

Angina; si^e Pharyngitis and Tonsillitis. 

in diphtheria, 663 

in scarlatina, 713, 752 
Antimony in catarrhal croup, 81 

in pseudo-membranous laryngitis, 102 

in pneumonia, 190 

in capillary bronchitis, 215 

excessive action of, in children, 190, 216 

in pleurisy, 243 
Antiseptic remedies in scarlatina, 750 
Antispasmodics in eclampsia, 553 

in laryngismus stridulus, 570 

in tetanus, 590 

in chorea, 608 

Aphtha ; see Follicular Stomatitis. 

fatty nature of deposit in, 303 
Apoplexy; see cerebral hemorrhage, 519 
Apparatus, mechanical, in infantile paralysis, 
631 

Appendix Cceci. 

catarrhal inflammation of, 453 
perforative ulceration of, 457 
article on diseases of coecum and appendix, 
447-462 

age as cause, 449 

sex as cause, 450 

intestinal concretions as cause, 451 

anatomical lesions of, 452 

cases of, 454 

symptoms of, 455 

duration of, 458 

prognosis in, 458 

diagnosis of, 459 

treatment of, 460 
Arsenic in chorea, 510 
iu scrofula, 842 
in eczematous affections, 908 
Artificial food for children, 332-337 
as cause of indigestion, 357 

Ascaris LuiiBRicoiDES. 
article on, 965-976 
description of, 961 
synonyms of, 961 
early age as cause of, 965 
disposition to, hereditary, 965 
seat of, 965 
number of, 965 
anatomical lesions in. 966 
condition of mucous membrane in, 966 
perforation of intestine by, 966 
hemorrhage from bowel in, 969 
verminous abscesses in, 967 
no diagnostic symptoms of, 967 



Ascaris lumbricoides, digestive disturbances 
caused by, 968 
restlessness caused by, 968 
peculiar physiognomy, caused by, 968 
mechanical effects of, 969 
effects caused by displacement or migra- 
tion of, 969 
dyspnoea and cough caused by, 969 
nervous symptoms caused by, 970 
diagnosis of, 971 
prognosis in. 971 
treatment of, 972-976 
caution in use of vermifuges, 972 
wormseed-oil in cases of. 972 
pinkroot in cases of, 973 
turpentine in cases of, 973 
calomel in cases of. 974 
santonin in cases of, 974 
kameela in cases of, 975 
general treatment in cases of, 975 
treatment of complications in cases of, 976 
diet in cases of, 976 

Ascaris Vermicularis. 
article on, 977 
description of, 962 
synonyms of, 962 
seat of, 977 
causes of, 977 
symptoms of, 977 
diagnosis of, 977 
prognosis in, 977 
treatment of, 977 
enemata in treatment of, 977 
ointments in treatment of, 978 
Assafoetida in chorea, 610 
Astringents in entero-coiitis, 410 

local use of, in diphtheria, 680 
Ataxia, locomotor, after diphtheria, 678 
Atelectasis pulmonum, and collapse of the 
lung, 135-158 
peculiarity of respiration in, 41, 137 
forms of, 135 
congenital, anatomical appearances 

in, 135 
congenital, causes, 136 
symptoms of, 137 
in early weeks of life, symptoms of 

{see collapse), 138 
diagnosis of, 141 
prognosis in. 141 
treatment of, 142, 143. 144 
effects of position in, 142 
post-natal {see collapse of lung), 144 
as cause of sclerema, 956, 959 
Atmospheric pressure as cause of deformities 

in rickets, 864 
Atrophy, muscular {see infantile paralysis), 
615 

Auscultation. 
of heart, 36 
of lungs, 42, 43, 44 

best position of child in, 43 
in true croup, negative results of, 96, 115 
in pneumonia, 170, 173, 177 
in bronchitis, 203, 205, 207, 208 
in pleurisy, 235 
of heart in chorea, 596, 601 
in bronchial phthisi*, 848 
in pulmonary phthisis, 850 
of head in rickets, 861 



INDEX. 



981 



Barthez. 

results of expectant treatment in pneumo- 
nia, ISS 

Baths. 

in treatment of cholera infantum, 441 
in treatment of skin diseases. 918, 935 
cold, as prophylactic in catarrhal croup, 

* in treatment of chorea, 612 
in grave cases of scarlatina, 742 
hot, in treatment of scarlatinous dropsy, 

753 
in treatment of tetanus, 590 
warm, in treatment of catarrhal croup, 
80, 82 
in eclampsia, 551 
in tetanus, 590 

in mild cases of scarlatina, 739 
in rubeola, 778 
in variola, 798 
Becquerel. pulse in children. 34 
Belladonna in catarrhal croup, 84 
in hooping-cough, 272 
in tetanus, 590 
in infantile paralysis, 629 
as a prophylactic in scarlatina, 757 
Benedict, case of laryngismus stridulus, 571 
Bennett, J. Hughes, restorative treatment of 
pneumonia, 187 
on bleeding in treatment of pneumo- 
nia, 189 
Berg, fungous nature of thrush, 321 
Billard, pulse in children, 34 
Bird, Golding, alum in hooping-cough, 274 
Bismuth, subnitrate of, in entero-colitis, 410 
Blebs (S(?e Bulla;), 923 

Bleeding, in severe spasmodic simple laryn- 
gitis, 82 
in pseudo-membranous laryngitis, 99 
in pneumonia, 187 
in bronchitis, 214 
in pleurisy, 243 
in hooping-cough, 271 
in gastritis, 383 
in typhlitis, 460 
in intussusception, 475 
in tubercular meningitis, 499 
in simple meningitis, 513 
in eclampsia, 531 
in tetanus, 589 

in atrophic infantile paralysis, 629 
in dropsy foUowing'scarlatina, 756 
in rubeola, 778 
Blisters, mode of using in children, 192 
in pneumonia, 192 
in pleurisy, 245 
Blood, condition of, in scarlatina, 730 
in measles, 773 
in variola, 793 
in typhoid fever, 823 
Bloodvessels of skin in sclerema, 959 
Bloody stools in intussusception, 468 
Bones, alterations of, in rickets, 862 

disease of, in congenital syphilis, 874 
Bothriocephalus latus, 963 
Bouchut, pulse in children, 34 

expectoration in pneumonia, 178 
stools in entero-colitis, 399 
Brain, condition of, in tubercular meningitis, 
483 
in simple meningitis, 509 



Brain, congestion of {see. cerebral congestion), 
515 
condition of, in cerebral hemorrhage, 521 
in tetanus, 585 
in chorea, 597 
in congenital syphilis, 875 
in scarlatina, 729 
in typhoid fever, 823 
Bretonneau, on nasal diphtheria, 665 



Bronchia. 

dilatation of, in capillary bronchitis, 200 
in chronic bronchitis, 203 
physical signs of, 208 
Bronchial abscess, in bronchitis, 201 

glands, tuberculosis of. 843, 847 

phthisis {see tuberculosis of bronchial 
glands). 
Bronchitis, connection of, with atelectasis, 151 

in typhoid fever. 830 

in hooping-cough, 266 

in measles, 768 

in scrofula, 838 

frequency and mortality of, 154, 156, 157 

effect of temperature and season upon mor- 
tality of, 162 

article on, 196-219 

definition of, 196 

synonyms of, 196 

forms of, 197 

predisposing causes of, age, sex, season, 
insuflBcient clothing, 197, 198 

exciting causes, 198 

anatomical alterations in, 199 
in acute ordinary form, 199 
in capillary form, 200 

dilatation of bronchia in, 200 

bronchial abscess in, 201 

condition of lung tissue in, 202 

lesions in chronic form, 203 

symptoms of simple acute form, 203 

aggravation of symptoms at night, 204 

duration of simple acute form, 204 

danger of collapse of lung in, 204 

symptoms of capillary form, 205 

duration of capillary form, 206 

symptoms and course of chronic form, 206 

physical signs in, 208 

cough in, 209 

sputa in capillary form of, 209 

peculiar cough in capillary form, 209 

respiration and pulse in, 209 

temperature in, 210 

expression in, 210 

urine in, 210 

diagnosis of, 210 

peculiarity of dyspnoea in, 211 

prognosis in, 212 

treatment of, 212-219 

importance of confinement to bed, 212 

bleeding in, 214 

emetics in, 214 

antimony in the capillary form, 215 

ipecacuanha in, 216 

external applications, cups, in, 215 

use of stimulants in, 217 

use of quinia in, 217 

treatment of chronic form, 218 
BuIIec, chapter* on, 923 



Cachectic Diseases, 



982 



INDEX. 



Calomel {see mercury), use in spasmodic 
croup, 82 
in membranous croup, 103 
use in diarrhoea, 407 

cholera infantum, 441 
tubercular meningitis. 502 
simple meningitis, 514 
chronic hydrocephalus, 535 
eczematous aflfections, 909 
as a vermifuge, 974 
Cannabis Indica in tetanus, 590 

Canula for Tracheotomy. 

details of size and form, 119 
Capillary bronchitis {see bronchitis), 200 

Carbolic Acid ; se^ Acid. 
Carpo-pedal spasms, 576 

in laryngismus stridulus, 565 

Cases, Illustrative. 

of chronic coryza, 60 

of pseudo-membranous laryngitis, 127 

of collapse of the lung, 152 

of cerebral pneumonia, 181 

of general emphysema, 222 

of chronic emphysema, 228 

of pneumothorax, 255 

of chronic pleurisy, 252 

of cyanosis, 284, 289 

of cardiac disease, 298 

of perforation of appendix coeci, 454 

of tubercular meningitis, 485 

apparent recovery from, 496, 506 

of cerebral hemorrhage, 524 

of laryngismus stridulus, 571-574 

of contraction with rigidity, 578 

of atrophic infantile paralysis, 620 

of progressive muscular sclerosis, 638 

of heart-clot in diphtheria. 674 

of paralysis following diphtheria, 676 

of mode of invasion of scarlatina, 707, 
711 

of grave form of scarlatina, 715 

of croup in. 720 

of convulsions in, 735 

of use of cold lotions in, 745-747 

of use of ice in angina of, 753 

of convulsions in measles, 762 

of fatal serous effusion in, 771 

fatal, of measles, 775 

illustrative of protective power of vacci- 
nation, 809 

of tinea, 952 
Catarrh of stomach and intestines (^ee indiges- 
tion), 356 

of stomach, 379 

in measles, 761 
Cauterization of variolous poclf to prevent pit- 
ting, 801 

in treatment of diphtheria, 679 
Cavities, tuberculous, 844 

Cerebral Congestion, article on, 515-518 

of less importance than usually consid- 
ered, 515 

West's views on, 517 

causes of, 517 

division into active and passive forms, 517 

symptoms of. 517 

terminations of, 518 

treatment of the two forms, 518 
Cerebral disease in congenital syphilis, 875 i 



Cerebral form of pneumonia, 183 
Cerebral hemorrhage, article on, 519-527 

definition and frequency, 519 

forms of, cerebral and meningeal, 519 

causes of, 520 

anatomical lesions of, 520 

of the meningeal form, 521 

transformation of the clot in, and forma- 
tion of pseudo-cyst, 522 

symptoms of cerebral form, 523 

case of, 524 

meningeal form, 524 

chronic hydrocephalus following menin- 
geal form, 525 

duration of, 525 

diagnosis of cerebral form, 526 

meningeal form, 526 

prognosis in, 526 

treatment of, 526 

depletion in, 526 

cold and counter-irritation in, 527 

treatment of paralysis following. 527 

chronic hj^drocephalus following, 527 
Cerebral symptoms, in pneumonia, 180 

in cholera infantum, 432 

in intussusception, 471 

in tubercular meningitis, 486, 490 

in simple meningitis, 510 

in cerebral congestion, 517 

in cerebral hemorrhage, 523 

in chronic hydrocephalus, 532 

in laryngismus stridulus, 564 

in contraction with rigidity, 576 

in chorea, 601 

absence of in atrophic infantile paralysis, 
618 

in mumps, 689 

in scarlatina, 707 

in measles, 771, 780 

in variola, 789 

in typhoid fever, 824, 826, 830, 834 

caused by worms. 970, 977 
Chambers, T. K., on poultices in pneumonia, 
193 

on calomel in diarrhoea. 408 
Chemical characters of false membranes, 

659 
Chenopodium, oil of, in treatment of worms, 

972. 978 
Chicken-pox : see Varicella. 
Chloral in tetanus, 590 
Chloroform in eclampsia, 554 

in laryngismus, 571 

Cholera iNFAxTtni, article on, 421-442 
general remarks on, 421 
definition and synonyms of, 421 
frequency of, 422 
causes of, 423 

great heat as a cause of, 423 
improper diet as a cause of, 423 
hygienic conditions favorable to, 425 
anatomical appearances and pathology of, 

425 
symptoms of, 430 
character of stools in, 430 

of vomiting in, 431 
course and duration of, 431 
diagnosis of, 433 
prognosis in, 433 
prophylactic treatment in, 434 
treatment of stage of evacuation, 435 

of stage of collapse, 437 



INDEX, 



983 



Cholera infantum, treatment of, importance of 
free supply of water in, 437 
miftura indica in, 438 
importance of rest in. 439 
treatment of stage of reaction. 440 
importance of attending to state of gums 

in, 441 
use of baths in, 441 
use of calomel in, 441 

Chorea, article on, 591-fil5 

definition and synonyms of, 591 
frequency of, 591. 606 
early age as predisposing cause of, 591 
other predisposing causes of, 591 
rheumatism as cause of, 593 
fear and other exciting causes of^ 595 
anatomical lesions in, 595 
lesions of heart in, 596 
brain in, 597 
spinal cord in, 597 
microscopical changes in spinal cord in, 

598 
portions of body affected in, 598 
prodromic symptoms of, 598 
symptoms of invasion of, 599 

' of the confirmed disease, 599 
respiratory muscles and heart at times af- 
fected, 600 
paralysis of sphincters in, 600 
loss of voluntary power in, 600, 618 
general symptoms in, 601 
condition of urine in, 601 
cardiac murmurs in, 601 
course of, 601 
effects of acute intercurrent disease upon, 

601 
duration of, 602 
frequency of relapses, 602 
nature of, 602 

probable seat of lesion in, 603 
alterations of blood as cause of, 603 
reflex irritation as cause of, 604 
embolism as cause of, 293, 604 
mode of action of rheumatism as cause of, 

606 
prognosis in, 606 
statistics of mortality in, 606 
diagnosis of, 606 
unfavorable symptoms in, 607 
duration of, 607 
treatment of, 607 
use of purgatives in, 608 
antispasmodics in, 608 
cimicifuga in. 608 
arsenic in, 61 
strychnia in, 611 
conium in, 611 
stimuli in, 611 
baths in, 612 

gymnastic exercises in, 613 
hygienic treatment of, 615 
Chronic bronchitis, 206 

pleurisy, 239 
Cimicifuga racemosa in chorea, 608 
Circulatory organs, diseases of, 282 
Clarke, J. L., state of spinal cord in tetanus, 586 

in chorea, 597 
Clinical examination of children, 17 
Club-foot in infantile paralysis, 632 
Cod liver oil in habitual indigestion, 366 
in rickets, 869 
in tuberculosis, 857 



Cod-liver oil in congenital syphilis, 876 

in eczematous affections, 908 
Caecum and appendix coeci, article on diseases 
of, 447-462 
(See also typhlitis, perityphlitis, and appen- 
dix.) 
synonyms and definition of, 447 
seat and character of, 448 
causes of, 449 
intestinal concretions and foreign bodies 

as causes of, 451 
anatomical lesions in, 452 
illustrative cases of, 454 
symptoms of, 455 
duration of, 458 
prognosis in, 458 
diagnosis of, 459 
treatment of, 460 
typhlitis, 455 
perforation of coecum, 457 
perforative ulceration of appendix, 457 
* perityphlitis, 457 

Coecum, symptoms of fecal distension of, 455 
perforative ulceration of, 457 
inflammation of {see typhlitis). 
Cold, as cause of dropsy after scarlatina, 722 
applications in tubercular meningitis, 501 
in simple meningitis, 514 
in eclampsia, 552 
in laryngismus stridulus, 671 
in tetanus, 590 
in scarlatina, 742 

Collapse of Lung. 

in bronchitis, 202, 204, 208 

in hooping-cough, 256 

in rickets, 867 

article on, 135-158 

in early weeks of life, symptoms of, 138 

cyanosis in, 139 

cases of, 139, 140 

diagnosis of, 141 

prognosis in, 141 

treatment of, 142 

of post-natal atelectasis, 144-158 

general remarks on the pathology of, 144- 
149 

identity of lobular pneumonia with, 146 

anatomical lesions in, 146 

congestion of lung accompanying, 147 

differences between condition of lung in, 
and in pneumonia, 148 

portions of lung affected in, 149 

causes of, and explanation of mode of pro- 
duction, 149 

symptoms of, 151 

diagnosis of, 155 

prognosis in, 156 

treatment of, 156 

use of emetics in, 157 

treatment of, when combined with bron- 
chitis, 157 
Coloration of skin, significance of changes of, 
22 

in infants, 30 

of face in pneumonia, 179 

in tubercular meningitis, 489 
Colostrum corpuscles, 341 
Compression of head in hydrocephalus, 536 
Concretions, intestinal, 451 
Condylomata in congenital syphilis, 873 

Congenital Svphilis ; see Syphilis. 



984 



INDEX. 



Congestion of the brain {see cerebral conges- 
tion), 515 
Congestion of the lungs, non-inflammatory, 
165 
in bronchitis, 202 
in typhoid fever, 830 
Conium in tetanus, 590 

in chorea, 61 1 
Constipation, as cause of diseases of the coe- 
cura, 450 
in intussusception, 468 
in tubercular meningitis, 487 
Constitutional diseases. 646 
Contagion of hooping-cough, 260 
of diphtheria, 653 
of mumps, 686 
of scarlatina, 697 
of rubeola, 758 
of sraall-pox, 783 
of varicella, 819 
of typhoid fever, 822 

of favus, 941 ^ 

of tinea, 948 
of alopecia areata, 954 
Contraction, with rigidity, article on, 574-582 
a rare affection, 574 
definition of, 574 
causes of, 575 

nature of, one of the forms of eclamp- 
sia, 575 
symptoms of, 575 
carpo-pedal spasms in, 576 
diagnosis of, from symptomatic con- 
traction, 577 
prognosis in. 677 
treatment of, 577 
case by Dr. J. F. Meigs, 578 
Contracture ; see Contraction. 

Convulsions, General, or Eclampsia, article 
on, 537-557 

general remarks on ; forms of, 537 

definition, synonyms, frequency, 538 

predisposing causes of, 538 

most frequent before age of seven 
years, 538 

nervous temperament as a predispos- 
ing cause of, 539 

hereditary nature of, 540 

exciting causes of, 541 

frequency of different forms of, 541 

prodromic symptotns of, 541 

symptoms of the attack, 542 
partial, varieties of, 544 
general, duration of, 544 

nature of, 545 

M. Hall's views on spasm of the lar- 
ynx, 545 

centric and eccentric causes of, 546 

no lesion as yet detected in, 547 

diagnosis of from epilepsy, 547 
the form of convulsion, 547 

prognosis in, 549 

treatment of, 550 

importance of discovering cause of 
attack, 550, 555 

treatment of attack, 551 

bleeding in, 551 

emetics in, 552 

antispasmodics and opium in, 553, 
554 

chloroform in, 554 
internal, definition of, 565 



Convulsions, internal, symptoms of paroxysm, 
565 
degree of laryngismus present, 566 
incomplete, or holding-breath spells, 

566 
rarely dangerous, 567 
in pneumonia. 180 
in hooping-cough, 263 
in tubercular meningitis, 489 
in simple meningitis, 510 
in meningeal apoplexy, 524 
in scarlatina, 710, 735 
uraemic, in scarlatina, 726 
in initial stage of measles, 761 
in later stages of measles, 771, 775, 780 
in typhoid "fever, 827, 830 
in worms, 970, 977 
Corson, cold affusions in scarlatina, 743 
Coryza, definition, synonyms, forms, fre- 
quency, 52 
causes of, 53 
anatomical lesions in, 53 
symptoms of mild form, 53 

of severe form, 54 
epistaxis in, 55 
duration of, 55 
prognosis in, 55 

in the course of other diseases, 56 
chronic, symptoms and duration of, 56 
treatment of acute, 58 
local, of acute, 58 
of chronic, 59 
case of chronic. 60 
in congenital syphilis, 872 
in scarlatina, 715 
Cough, in simple laryngitis, 64 

violent in chronic laryngitis, 65 
in true croup, 94 
in pneumonia, 177 
in pleurisy, 238 
in hooping-cough, 260-263 
in spasmodic simple laryngitis, 72, 74 
in bronchial phthisis. 847 
in pulmonary phthisis, 849 
in measles, 763, 768 
in typhoid fever, 830 
Countenance, alterations of, 21 
Counter irritation in tubercular r^ieningitis,, 
501 
in simple meningitis, 514 
in chorea, 612 

in pulmonary complications of measles., 
779 
Country residence, impo^rtaace of in summer, 
403, 437 
in tuberculosis, 8-56 
Cowhage as a vermifiage, 974 

Cow-Pox ; see Vaccine Disease. 
Cracked-pot sound in bronchial phthvsis, 848 
Cream, proportion of in cow's milk, and mode 
of determining, 333 
in human milk, 340 
Croup, diphtheritic, 664 

relations of to pseudo-m-embranous laryn- 
gitis, 86, 664 
false, spasmodic, or catarrhal {s-ee spas- 
modic simple laryngitis). 69 
true or membranous {see pseudo membran- 
ous laryngitis), 86 
secondary, in scarlatina, 719 
tracheotomy in, 106 
Crust, vaccine, characters of, 814 



INDEX. 



985 



Crusta lactea {.tee eczema capitis), 901 
Cry, characters of the. 24 

peculiar in meningitis, 4S7 

alterations of in simple laryngitis, 64 

peculiar in sclerema, 957 
Crystalli : .-t?e Varicella. 
Currie. cold affusions in scarlatina, 742 
Cutaneous diseases, S77 

not transmitted by vaccination, 812 
Cutaneous diphtheria, 666 

surface, signs from, 22, 30 

CrAxosis. in collapse of the lung, 139 
article on, 282-290 
definition of, 282 
anatomical appearances in, 282 
illustrative cases of 284, 289 
theories of mode of production of, 286 
symptoms of, 286 

date of appearance of lividity, 287 
modes of death in, 288 
duration of life in, 288 
treatment of the form due to atelectasis, 
289 
of paroxysms of dyspnoea, 289 
hygienic treatment, 290 
effect of position on. 290 
neou'iturum^ Prof. Meigs on treatment of, 
142 

CrxANCHE Parotidea ; SM Mumps. 
Cynanche maligna {see diphtheria), 651 

tonsillaris {see tonsillitis), 244 
Cyst, pseudo-, in arachnoid, in meningeal 
apoplexy, 522 

Deafness after diphtheria, 677 
Decubitus of children, 28 
in different diseases. 29 
in tubercular meningitis, 491 
Deformities in rickets, 862 
Deglutition, diflficulty of in bronchial phthisis, 
847 
in retro-pharyngeal abscess, 354 
in scarlatina, 714 
Dentition as cause of entero-colitis, 390 
of cholera infantum, 425 
of eclampsia, 541 
of laryngismus stridulus, 559 
of infantile paralysis, 618 
impeded in rickets, 861 
Desiccation in variola, 787 
Desnos and Huchard on cardiac complications 

in variola, 790, 793 
Desquamation in scarlatina, 705 
in measles. 764 
in small-pox, 788 
in erysipelas, 886 
Development, degree of as aid in diagnosis, 27 

Diagnosis in children, difficulties of, 18 
general method of, 19 
of simple laryngitis without spasm, 66 
of spasmodic simple laryngitis from true 
croup, 76 
from laryngismus stridulus, 567 
of pseudo-membranous laryngitis, 97 
of catarrhal from true croup. 76, 98 
of idiopathic from diphtheritic croup, 90, 

98 
of atelectasis from pneumonia, and pleu- 
risy, 155 
of collapse of the lung, 155 



Diagnosis of pneumonia from bronchitis, pleu- 
risy, (fee, 182-184 

of cerebral pneumonia from cerebral dis- 
ease, 183 

of bronchitis from pneumonia, 210 
from hooping-cough, 210 

of emphysema, 229 

of pleurisy from pneumonia, 241 

in early stage from one of the exan- 
themata, 242 

of pneumothorax, 258 

of hooping-cough from acute laryngitis, 
267 
from tuberculosis of the bronchial 
glands, 268 

of aphthae from ulcero-membranous stom- 
atitis, 303 

of ulcerative stomatitis from gangrene of 
the mouth, 315 

of thrush, 330 

of tonsillitis, 345 

of simple pharyngitis, 351 

of retro-pharyngeal abscess, 355 

of indigestion, .361 

of simple diarrhoea, 373 

of gastritis, 382 

of entero-colitis, 402 

of cholera infantum, 433 

of dysentery, 444 

of diseases of coecum and appendix, 459 

of intussusception, 472 

of tubercular meningitis, 492 

of simple meningitis, 512 

of cerebral hemorrhage, 526 

of chronic hydrocephalus, 533 

of eclampsia, 547 

of laryngismus stridulus, 567 

of contraction with rigidity, 577 

of tetanus nascentium, 588 

of chorea, 606 

of atrophic infantile paralysis, 628 

of facial paralysis, 633 

of progressive muscul.'ir sclerosis, 642 

of acute rheumatism, 648 

of diphtheria, 671 

of malarial fever, 692 

of mumps, 689 

of rickets, 865 

of tuberculosis, 854 

of tuberculous peritonitis, 854 

of tuberculosis of mesenteric glands, 855 

of congenital syphilis, 874 

of scarlatina, 732 

of rubeola, 733 

of variola, 794 

of vaccine disease, 808 

of varicella. 821 

of typhoid fever, 832 

of scrofula, 840 

of erythema fugax, 879 

of erythema, 880 

of erysipelas, 887 

of roseola, 893 

of urticaria, 896 

of eczematous affections, 905 

of herpes, 917 

of scabies, 920 

of pemphigus, 925, 927 

of rupia, 927, 930 

of ecthyma, 930 

of strophulus, 932 

of lichen, 934 

of prurigo, 935 



986 



INDEX. 



Diagnosis of favus, 944 

of tinea tonsurans, 950 
of tinea circinata, 951 
of alopecia areata, 955 
of sclerema, 958 
of ascaris lumbricoides, 971 
vermicularis, 977 

Diaphoretics ; see. Formulas. 

hot bath as, in scarlatinous dropsy, 756 
Diarrhoea in thrush, 328 

fiiniple or catarrhal, article on, 367-377 

nature of, 367 

causes of, 368 

improper diet as a cause, 368 

anatomical lesions in, 369 

symptoms of, 371 

course of, 373 

diagnosis of. 373 

prognosis in, 373 

treatment of, 373 

of chronic form, 376 
inflammatory i^see, entero-colitis), 383 
in rickets, 861 

in tuberculous peritonitis, 852 
in tuberculosis of mesenteric glands, 854 
in scarlatina, 728 
in measles, 764, 780 
in variola, 801 -' 
in typhoid fever, 824, 828, 834 
Diday, on infantile syphilis, 871 
Diet (&?6 also food), in pneumonia, 195 
after tracheotomy, 126 
in chronic bronchitis, 219 
in pleurisy, 243 
in thrush, 331 

after premature weaning, 332-337 
in indigestion, 364 
improper, as cause of indigestion, 357 

as cause of diarrhoea, 368 
proper, in diarrhoea. 373 
in gastritis, 382 
in acute entero-colitis, 405 
in chronic entero-colitis, 414 
improper as cause of cholera infantum, 

423 
suitable for children, 335, 434 
in tubercular meningitis, 504 
in laryngismus stridulus, 568 
in diphtheria, 684 
in rickets, 869 
in tuberculosis, 856 
in congenital syphilis, 876 
in scarlatina, 739, 757 
in rubeola, 776 
in variola, 799 
in typhoid fever, 835 
in scrofula, 840 
in erysipelas, 890 
as cause of urticaria, 895 
in urticaria, 897 
in rupia, 928 
in ecthyma, 930 
in ascaris vermicularis, 976 
Digestive organs, diseases of, 301 

disturbances in early stage of rickets, 860 

in tuberculous peritonitis, 852 

in tuberculosis of mesenteric glands, 
854 

in variola, 788 

in typhoid fever, 824, 825, 827 

in erythema intertrigo, 879, 882 

caused by worms, 968 



Digitalis in scarlatinous dropsy, 757 
Dilatation of bronchia, 200 
Diphtheria, article on, 651-685 

definition and synonyms of, 651 
history of, 652 

statistics of frequency of, 653, 655 
epidemic, contagious, and infectious na- 
ture of, 653 
influence of season upon, 654 
table showing monthly mortality of, 655 
influence of age upon, less than in croup, 

656 
nature of: a constitutional disease, 656 
pathological anatomy of, 657-662 
development of false membranes, 657 
color and consistence of false membranes, 

658 
microscopic anatomy of false membranes, 

658 
chemical characters of false membranes, 

659 
condition of mucous membrane in, 659 
lesions in croup following, 660 
seat of exudation in, 660 
exudation on skin in, 660 
condition of submaxillary glands in, 661 
fatty degeneration of heart in, 661 
condition of kidneys in, 661 
lesions in secondary form, 661 
forms of, 662 
symptoms of, 662 
condition of throat in, 662 
difficulty in deglutition not constant, 663 
danger of exudation extending to larynx, 

664 
symptoms of croup in, 665 
nasal variety of, 665 
culaneous, symptoms of, 665 
invasion often insidious, 667 
general symptoms of mild form, 667 

of severe form, 668 
urine in, 668 
eruption in, 669 
course in fatal cases, 669 
malignant symptoms in, 669 
duration of, 670 
prognosis in, 670 
diagnosis of, 671 

from scarlatina, 671 
albuminuria in. 672 
heart-clot in, 673 

Richardson's account of symptoms of. 
674 

Robinson on, 675 

cases of, 674 
endocarditis in, 675 
paralysis following, 675 

order of muscles afl"ected in, 677 

motion and sensation both aff'ected, 
677 

result usually favorable, 677 

explanation of, 677 
locomotor ataxia following, 678 
treatment of. 678-685 
local applications to throat in, 679 
solvents for the false membranes, 680 
use of gargles in, 681 
local use of ice in, 682 
external applications in, 682 
injections in nasal form of, 682 
general treatment of, 682 
emetics and purgatives in, 683 
necessity for supporting remedies, 683 



INDEX. 



987 



Diphtheria, stimulants in, 684- 
diet in. 684 

necessity for absolute rest, 684 
treatment of the paralysis after, 685 
of heart clots, 685 
Diuretics (5fe formulte), in scarlatinous drop- 
sy, 756 
Dress, suitable for children, 85. 404, 434 
Drinks, manner of taking as a diagnostic sign. 

49 
Dropsy, after scarlatina {see article on scarla- 
tina), 721-728 
treatment of. 754-757 
after measles. 771 
Duchenne, on progi-essive paralysis, 637 
Dysentery, article on, 442-447 
definition of. 442 
causes of. 442 
anatomical lesions in, 443 
symptoms of, 443 
diagnosis of, 444 
prognosis in, 444 
treatment of, 444 

Earache, violent crying in, 25 
Eclampsia {see convulsions), 537 
Ecthyma, article on, 929-931 

definition, synonyms, varieties, 929 
causes of, 929 

diagnosis of. from rupia, 927, 930 
prognosis in, 930 
general treatment of, 930 
local treatment of, 931 
v^dgare. 

symptoms of, 929 
ill f ant lie. 

symptoms of, 930 
Eczematous affections, article on, 898-913 
definition of, 898 
elementary lesions in, 898 
eruption frequently mixed in, 898 
seats of eruption in, 899 
forms of, 899 
causes of, 899 
diagnosis, 905, 921 
prognosis in, 906 
no danger in curing quickly, 906 
principles of treatment of, 906 
general treatment in. 907 
attention to digestive symptoms in, 907 
use of arsenic in, 908 

of codliver oil in, 908 
of iron in, 908 
of calomel in, 909 
local treatment of, 909-913 
cool and emollient applications in, 909 
benzoated oxide of zinc ointment in, 

910 
mode of removing crusts in, 910 
lotions in, 911 
ointments in, 911 
spiritus snponatus kalinus of Hebra in, 

912 
solutions of potash in, 911 
tarry applications in, 913 
use of soaps in, 912 
mercurial applications in, 913 
eczfina siwphx. 
symptoms of, 899 

diagnosis of from scabies, 905, 921 
from sudamina, 906 
eczema pnpu/osinn. 
symptoms of, 900 



Eczematous affections. 
eczema piistulosum, or impetiginoides, symp- 
toms of, 900 
diagnosis from favus, 906 
prognosis in, 906 
eczema, capitis. 
symptoms of, 901 
condition of scalp in, 901 
chronic form of, 902 
mode of removing crusts in, 910 
ecze7)ia, faciei. 

symptoms of, 902 
eczema larvale. 

general symptoms in, 903 
duration of, 903 
eczevia graiuilatiun. 

symptoms of, 904 
eczema tarsi. 

symptoms of, 904 

treatment of, 913 

impetigo fisurata, 904 

spnrsa, 904 
eczema chroniciim.. 

common to all varieties, 905 
symptoms of, 905 
seats of, 905 
duration of, 905 
general treatment of, 908 
local treatment of, 912 
Electrical batteries, 630 
Electricitv in chorea, 613 

in infantile paralysis, 622, 630 
in facial paralysis, 634 
in progressive paralysis, 637, 645 
in diphtheritic paralysis, 685 
Electro-muscular contractility in infantile 
palsy, 620, 622 
in facial palsy, 634 
in progressive palsy, 637 
Embolism in endocarditis as cause of chorea, 

293, 604 
Emetics it? catarrhal croup, 80, 83 
in membranous croup, 100 
in collapse of the lung, 157 
in bronchitis, 214 
in hooping-cough, 273 
in eclampsia, 552 
in diphtheria, 683 
Emphysema, time and cause of existence, 220 
anatomical appearances, 220 
vesicular, 220 
interlobular, 221 
causing pneumothorax, 221 
case of, 222 

causes of, age, previous disease, &c , 223 
mechanism of production, 223 
symptoms, rational, 225 
physical signs, 227 
case of, 228 
diagnosis of, 229 
prognosis in, 229 
treatment of, 230 
association with pneumonia, 168 
Empyema, symptoms and course of {see pleu- 
risy), '240 
paracentesis in, 248 
Erapyreumatic oil of Chabert. as a vermifuge, 

975 
Endocarditis, in diphtheria, 675 
in scarlatina, 729 
acute, 292 

symptoms of, 292 
prognosis in, 293 



INDEX. 



Endocarditis, acute, anatomical appearances 
in, 293 
embolism in, in connection with cho- 
rea, 293 
treatment of, 293 
Enemata, astringent, in chronic entero-colitis, 
418 
in dj'sentery, 445 
in disease of ccecum, 461 
of air and fluids in intussusception, 475 
in eclampsia, 553 
in diphtheria, 684 
in treatment of worms, 977 
Enteritis in measles, 770 
in variola, 788, 801 
Entero-colitis, article on, 383-421 
definition of, 383 
frequency of, 384 
improper food and intense heat as causes 

of, 385 
table of mortality in, 386 
analoojies to camp diarrhoea, 389, 395 
dentition and weaning as causes of, 390 
anatomical lesions in, 391 
seat of disease in, 391 
condition of intestinal follicles in, 393 
lesions in chronic form, 394 
microscopic changes in intestines, 395 
condition of stomach in, 396 
of liver in, 396 

of mesenteric and mesocolic glands in, 396 
pathology of, 397 
symptoms of in acute form, 398 
condition of stools in acute form, 398 

of abdomen in acute form, 400 
vomiting in acute form, 400 
erythema of buttocks in acute form, 401 
duration of acute form, 401 
symptoms of chronic form, 401 
course and duration of chronic form, 402 
diagnosis of, 402 
prognosis in, 402 

treatment of acute form, 403-414 
prophylactic, 403 

necessity for change of residence, 403 
importance of exercise in open air, 405 
diet in, 405 

therapeutical treatment of, 406 
use of calomel in, 407 
use of opium in, 409 
use of astringents and absorbents in, 410 

of tonics and stimulants in, 412 
remedies for vomiting in, 412 
treatment of chronic form, 414-421 
diet in chronic form, 414 
creasote in, 414, 419 
use of raw meat in chronic form, 415 
nitrate of silver in, 417 
astringent enemata in, 418 
sulphuric acid in, 419 
tonics and stimulants in, 420 
Epidemic nature of diphtheria 653 

of mumps, 686 

of scarlatina, 698 

of rubeola, 758 

of variola, 782 

of varicella, 820 

of typhoid fever, 822 

of roseola. 891 
Epilation in favus, 946 

in tinea, 951 
Epistaxis in coryza, 57 
in measles, 763 



Epistaxis in bronchial phthisis, 847 

in typhoid fever, 829 
Ergot, in infantile paralysis, 629 
Eruption in diphtheria, 669 

in mild cases of scarlatina, 702 

in grave cases of scarlatina, 711, 715 

in measles, 763 

in malignant measles, 767 

in variola, 784 

in varioloid, 792 

in varicella, 820 

in typhoid fever, 824, 826, 829 

in erythema fugax, 878 
intertrigo, 879 
nodosum, 880 

in erysipelas. 885 

in roseola, 892, 893 

in urticaria, 895, 896 

in eczematous affections, 899-905 

in herpes, 914-917 

in scabies, 919 

in pemphigus, 924 

in rupia, 926, 927 

in ecthyma, 929, 930 

in strophulus, 932 

in lichen, 933 

in prurigo, 935 

in psoi'iasis, 936 

in pityriasis, 937 

in ichthyosis, 937 

in favus, 942, 943 

in tinea, 949. 950 
Eruptive fevers, 694 
Erysipelas, article on, 883-891 

definition and forms of, 883 

frequency of, 883 

causes of, 883 

following vaccination, 884 

epidemic and endemic nature of, 884 

starting-point of eruption, 884 

symptoms of, 884 

characters in very young infants, 885 

sloughing of skin in, 885 

characters of in older children, 885 

desquamation in, 886 

abscesses following, 886 

febrile symptoms in, 886 

typhoid symptoms in, 886 

duration of, 886 

diagnosis of, 887 

prognosis in, 887 

treatment of in young infants, 888 

local applications in, 888 

tr. ferri. chl. in, 889 

treatment of in older children, 890 

stimulants and tonics in, 890 

local applications in, 890 
Erythema about anus in thrush, 329 

of buttocks in entero-colitis, 401, 879 

article on, 878-883 

definition and forms, 878 
fugax. 

symptoms of, 878 

diagnosis of from scarlatina, 879 
from erysipelas, 880 
from roseola, 881 
intertrigo. 

seat of eruption, 879 

character of eruption, 879 

l^lceration in, 879 

form of occurring in connection with diar- 
rhoea, 879 

prognosis in, 881 



INDEX. 



989 



Erythema intertrigo, treatment of, SSI 

local applications in, SSI 

attention to digestive derangement in, 882 
iiodosjitn. 

symptoms of, SSO 

diagnosis of from phlegmonous erysipelas, 
SSI 

prognosis in, SSI 

treatment of, SS2 

tonics and stimulants in, SS3 

local applications in, 883 
Essay, introductory, 17 
Essential convulsions {s^e convulsions). 
Essera [s^e urticaria), 894 
Examination, clinical, in children, 17 

difficulties of, 17, 18, 19 

of abdomen, 46 

of the heart. 36, 37 

of mouth and fauces, 47 

of the pulse, 33, 34, 35 
Exercise in open air, importance of, 405 
Expectoration, nummular, in measles, 764 

in true croup, 95 

in pneumonia, 178 
Expiratory respiration in bronchitis, 209 
External applications {see local applications). 



Facial paralysis {see paralysis). 
Facies {sp-e physiognomy). 
False membrane, in croup, characters of, 90 
in secondary croup, 91 
extent of and frequency with 
which bronchia are invaded, 90 
action of chemical reagents upon, 680 
in capillary bronchitis, 200 
in diphtheria, 657 
in scarlatina, 713 
Fauces, examination of, 47, 48 
' in membranous croup, 91 
in simple pharyngitis, 350 
in diphtheria, 660 
in scarlatina, 704, 713 
in measles, 762 
Favus, article on, 941-948 

definition and synonyms, 941 
varieties and frequency of, 941 
description of the fungus which causes, 939 
contagion as cause of, 941 
occurs in lower animals, 942 
other causes of, 942 
symptoms of, 942 
nature of, 944 
diagnosis of, 944 
prognosis in, 945 
general treatment of, 945 
local treatment of, 946 
mode of removing crusts in, 946 
epilation in, 946 
parasiticides in, 947 
dispersHS. 

eruption in, 942 
course of^ 943 
condition of hairs in, 943 
baldness following, 943 
seats of the eruption, 943 
covffrtns, 943 
eruption in, 943 
Fecal accumulation in coecum, symptoms of, 
455 
diagnosis of, 473 
as cause of eclampsia, 556 
Fevers, eruptive, 694 



Fever, scarlet (see scarlatina), 694 

in variola, subsides on appearance of erup- 
tion, 787 
secondary in variola, 787 
typhoid, 822 

febrile action in, 827 
Finlayson, normal temperature in children, 38 
Follicles of intestine in entero-colitis, 393, 395 
Fomites as means of transmitting scarlatina, 
698 
variola, 783 
Food, artificial, 331-341 

gelatin, for infants, 338 
Merei's, for infants, 339 
improper, as cause of indigestion, 357 
of diarrhoea, 368 
of entero-colitis, 385 
of laryngismus stridulus, 559 
Foot-baths, in treatment of diseases, 192, 214, 
778 

Formulary of receipts recommended. 

Alteratives. 
Formula for mixture of iodide of potassium 
and bichloride of mercury, 500 
for iodide of potassium and compound 

decoction of sarsaparilla, 841 
for iodide of potussium, syrup of 
iodide of iron, and syrup of ginger, 
841 
Antacids and alkalies ; laxatives. 
Formula for mixture of soda, rhubarb, and 
paregoric, 342 
of magnesia and tr. thebaic, 342 
of sulphate of magnesia and rhubarb, 

375 
of sulphate of magnesia and laud- 
anum, 375 
of soda, blue mass, and paregoric, 407 
of crabs' eyes. 410 
for neutral mixture, 414 
of acetate and bicarb, potash and 
opium, 649 
Antiseptic. 
Formula for mixture of chlorinated lime, 309 

Anthelmintics. 
Formula for mixture of ol. chenopodii, 973 

of spigelia, magnesia, and manna, 

973 
of ol. terebinth, and magnesia, 974 
of santonin, &c., 974 
A Jitispasmodics . 
Formula for pills of belladonna, opium, and 
valerian, 272 
for mixture of belladonna and opium, 272 
of hydrocyanic acid, 273 
Astringoits. 
Formula for mixture of alum and honey of 
roses, 302, 344 
of sulphate of copper and cinchona, 

308, 309 
of sulphate of copper and quinia, 353 
for aromatic syrup of galls, 411 
of morph. sulph., and dil. sulph. acid, 

414 
of soda, krameria, and opium, 907 
of nitrate of silver, 417 
solution of nitrate of silver, 417 

of pernitrate of iron and nitric acid, 

4i8 
of aromatic sulph. acid, 419 

opium and krameria, 420 
of acetate of lead and acetic acid, 436 



990 



INDEX. 



Fehtifuges and (linreiics {see also alkalies). 
Formula for mixture of citrate of potash, 
ipecac, and paregoric, 83, 218 
of ipecac, opium, sp. sether. nitrosi, 

213 
of morphia, liq. ammon. acet., 216 
of iodide of potassium and sarsaparilla, 

244 
of squill and digitalis, 245 
of carbonate of potash, antimony, and 
opium, 68 
senega and opium, 68 
of acetate of potash, digitalis, and squill, 

757 
of bitart. of potash, juniper, and sp. 

^theris nitrosi, 756 
of powders of sulphurated antimony and 
Dover's powder, 83, 191 
of opium, ipecac, and nitrate of pot- 
ash, 252 
Foods. 
Formula for gelatin-food for children, 338 
for Merei's food for children, 339 
for preparation of raw meat, 415 
Laxntives {see also antacids). 
' Formula for mixture of sulphate of soda, senna, 
and laudanum, 460 
for pill of opium and colocynth, 461 
of blue pill, castor oil, and aromatic syrup 
of rhubarb, 579 
Local applications. 
Formula for lotion of carbonate of potash and 
sulphur, 911 
of lime and sulphur, 922 
of bichloride of mercury, 911 
of soft soap and alcohol (Hebra's sp. 
saponatus kalinus), 912 
for ointment of elder flowers, 918 

of glycerin and ung. aq. ros., 740 
for benzoated oxide of zinc ointment 

(Bell's formula), 910 
for mercurial ointment to prevent pitting 

in variola, 803 
for ointment of nitrate of mercury and 
belladonna, 60 
of protiodide of mercury, 912 
of calomel and camphor, 912 
of ammon. chl. of mercury with sul- 
phur, 952 
of tar and vin. opii, 913 
of tar and iodine, 952 
of sulphur and carbonate of potash 

(Wilson), 922 
of sulphur and carb. potash (Hel- 
merich), 922 
Nervous sedatives. 
Formula for mixture of antimony, valerian, 
and paregoric, 69 
of antimony, valerian, and laudanum, 
195 
Nervous stimulants. 
Formula for mistura indica, 438 

Specijic remedies. 
Formula for mixture of carbonate of potash in 
hooping-cough, 274 
of alum and conium in hooping-cough, 

275 
of alum in hooping-cough, 274 

and belladonnain hooping-cough, 
276 
To7iics. 
Formula for mixture of cod-liver oil, 366 
of nux vomica and gentian, 377 



Formula of tr. ferri chl., acetic acid, and sp. 
Mindereri, 420, 499, 751 
of quinia, morphia, and sulph. acid, 

650 
of quinia and dil. sulph. acid, 217 
of elix. cinchona and cura^oa, 217 
of arsenic and bitter wine of iron, 908 
Forster, temperature in new-born children, 37 
Fox, Wilson, on softening of stomach, 380 
on use of cold in treatment of hyper- 
pyrexia, 747 
French measles {see roseola), 891 
Frequency of diseases {see statistics). 
Fuller, statistics of tracheotomy, 106 
Fungi in skin diseases {see parasites). 
Fungous origin of measles, 759 

Gairdner, collapse of the lung, 144 
lesions in bronchitis, 201 
difference between dyspnoea of pneumonia 
and bronchitis, 21 1 
Galls, aromatic syrup of, 411 
Gangrene, of mouth {see gangrenous stoma- 
titis), 309 
of pharynx in diphtheria, 659 

in scarlatina, 713 
of skin in erysipelas, 886 
Gargles in diphtheria. 681 
Gastritis, article on, 377-383 

frequency and nature of, 377 
causes of, 378 
anatomical lesions in, 379 
softening of stomach in, 380 
symptoms of, 381 
diagnosis of, 382 
prognosis in, 382 
treatment of, 382 
Gastromalacia {see softening of stomach). 
Gastrotomy in intussusception, 476 
General diseases, introductory remarks upon, 

646 
Gerhard, G. S., on chorea, 592 
Gestures, significance of, 29 
Glands, bronchial, tuberculosis of, 843, 847 
cervical, in scarlatina, 714 
intestinal, in scarlatina, 730 

in typhoid fever, 823 
mesenteric, tuberculosis of, 846, 853 
parotid, in mumps {see mumps). 

in scarlatina, 714 
submaxillary in diphtheria, 661, 663 

enlarged in some cases of mumps, 687 
enlarged in scarlatina, 714 
Glottis, spasm of, in eclampsia, 545 
{see laryngismus stridulus), 557 
Golis, on treatment of hydrocephalus, 535 
Gregory, cold affusions in scarlartina, 742 
Guersant, mortality of true croup, 90 
Guinier, statistics of paracentesis, 248 
Gum {see strophulus), 931 
Gummy tumors in congenital syphilis, 875 
Gums, importance of lancing in cholera infan- 
tum, 441 
in laryngismus, 568 
Gutta pereha, solution of, to prevent pitting 

in variola, 803 
Gymnastic exercises in chorea, 613 
in infantile paralysis, 631 

Htemoptysis in pulmonary phthisis, 850 
Hair, in favus, 943, 944 

in tinea, 949, 951 

in alopecia areata, 954 



INDEX. 



991 



Hnll, Marshall, on spasm of glottis in eclamp- 
sia. 545 
on nature of laryngismus, 563 
Ilaramond. electrical condition of muscles in 

infantile paralysis, 623 
Barley, John, on connection of scarlet and 

enteric fevers, 730 
Harris, R. P., on hereditary nature of eclamp- 
sia, 540 
Head, peculiarities of, in hydrocephalus, 531 
in rickets, S62 
soft spots on, in rickets, 862 
Heart, physical examination of, 36, 37 
sounds of. 36 

diseases of, article on, 290-300 
(see pericarditis and endocarditis.) 

causes of, 290 
chronic valvular diseases of, 293 
causes of, ?93 

anatomical appearances in, 294 
symptoms of aortic disease, 295 

prognosis in, 295 
symptoms of mitral obstruction, 296 

prognosis in, 296 
symptoms of mitral regurgitation, 297 

prognosis in, 297 
compensation for, efiected by growing 

heart, 298 
tendency to improve by time, 298 
treatment of, 298 
illustrative cases of, 298 
in chorea, 596 

irregular aclion of, in chorea, 600 
fatty degeneration of, in diphtheria, 661 
inflammation of endocardium in diph- 
theria, 675 
inflammation of membranes of, in scarla- 
tina, 729 
Heart-clot in diphtheria, 673, 685 

in scarlatina, 731 
Heat, intense, as cause of entero-colitis, 385 
Heat of surface (see temperature). 
Hebra, on treatment of eczema, 912 
Helminthocorton as a vermifuge, 975 
Hemiplegia in chorea, 601 

in cerebral hemorrhage^ 524 
cerebral, diagnosis of from facial paraly- 
sis, 633 
Hemorrhage,, during paroxysms of hooping- 
cough, 261 
intestinal, in intussusception, &c., 472 
in typhoid fever, 830, 834 
Herpes, article on, 913-918 
definition of, 913 
varieties of, 914 
frequency of, 914 
causes of, 914 
diagnosis of, 917 
prognosis in, 917 
general treatment of, 918 
local treatment of, 918 
'pldyctenodes. 

seat of eruption in, 914 
symptoms of, 914 
diagnosis of from pemphigus, 917 
treatment of, 918 
lahialis. 

seat of eruption in, 915 
symptoms of, 915 
local applications in, 918 
zoster. 

definition of, 916 
seats of, 916 



Herpes zoster, character of eruption, 916 

course and duration of, 916 

general symptoms in, 916 

pain in, 916 

diagnosis of, 917 

local applications in, 918 
circinatus {see tinea circinata), 950 
iris. 

symptoms of, 917 

seat of, 917 

parasitic nature of, 917 

diagnosis of from roseola annulata, 917 

treatment of, 918 
Hewitt, Grailly, on collapse of the lung in 

hooping-cough, 265 
Hives {see urticaria), 894 

Hillier, indications for bleeding in pneumonia, 
187 

on pathology of infantile paralysis, 624 

albuminuria in diphtheria, 673 
Holding-breath spells {see convulsions, inter- 
nal), 566 
Hooping-cough, article on, 259-281 

definition, synonyms, frequency, 259 

causes, influence of age, 260 

contagion and epidemic influence, 260 

stages of, 260 

symptoms and duration of first stage, 260 
of second stage, 261 

character of paroxysms, 261 

hemorrhages during this stage, 261 

convulsions during this stage, 262 

duration of paroxysms, 262 

number of paroxysms, 262 

symptoms and duration of third stage, 262 

absence of general symptoms in, 263 

urine in, 263 

total duration of, 263 

convulsions as a complication, 263 

excessive laryngismus as a complication, 
264 

collapse of the lung as a complication, 265 

bronchitis as a complication, 266 

pneumonia as a complication, 266 

vomiting in, 267 

emphysema as a sequel, 267 

tuberculosis and scrofula as sequelae, 267 

diagnosis of from acute catarrh, 267 

from tuberculosis of bronchial glands, 
268 

prognosis in, 268 

nature of, 269 

anatomical lesions, 269 

mortality in, 269 

treatment of simple form, 270 

bloodletting in, 271 

belladonna in, 272 

hydrocyanic acid in, 273 

carbonate of potash in, 274 

alum in, 274 

inhalations in, 276 

local applications in, 277 

treatment of complications of, 278 
of paroxysms of, 280 

hygienic treatment of, 280 
Hunger, crying from, 25 
Hunt, S. B., change of residence in chronic 

diarrhoea, 404 
Hutchinson, J., on transmission of syphilis by 
vaccination, 813 
alteration of teeth in congenital syph- 
ilis, 873 
Hydrencephalic cry, 487 



992 



INDEX. 



Hydrocephalus, acute {see tubercular menin- 
gitis), 
chronic, following meningeal apoplexy, 
525 
article on, 528-537 
forms of, 528 

anatomical appearances in, 528 
analysis of fluid in, 529 
causes of internal form, 580 

externa] form, 530 
symptoms of, 531 
enlargement of head in, 531 
cerebral symptoms in, 532 
mode of death in, 533 
diagnosis of from rickets of the skull, 
533 
from hypertrophy of the brain, 
534 
prognosis in, 534 
treatment of, 535 
use of mercury in, 535 
compression of head in, 536 
paracentesis in, 536 
injections into cranial cavity in, 537 
Hydrochloric acid in diphtheria, 679 
Hydrocyanic acid in hooping-cough, 273 
Hygienic conditions, influence of unfavorable, 
425 
treatment in chorea, 615 
in measles, 776 
Hypertrophy of tonsils {see tonsils, chronic en- | 

largement of), 346 
Hyposulphites, use of in scarlatina, 750 

lee, local use of in eclampsia, 555 
in tetanus, 590 
in diphtheria, 682 
in scarlatina, 749, 752 
in angina of scarlatina, 752 
Ichthyosis, symptoms of, 937 

treatment of, 937 
Ileus (.»ee intussusception). 
Impetigo {see eczema impetiginoides). 
larvalis {see eczema larvale), 903 
granulata (s^e eczema granulatum), 904 
figurata, 904 
sparsa, 904 
Incubation, of scarlatina, 698 
of measles, 759 
of small-pox, 783 
Indigestion, article on, 356-367 

definition, frequency, forms, 356 

causes of, 357 

symptoms of occasional form, 358, 359 

of habitual form, 359, 360 
diagnosis of, 361 
prognosis in, 361 

treatment of occasional form in infants, 
362 
in older children, 362 
of habitual form, 363 
as cause of eclampsia, 556 
Infantile paralysis {see paralysis), 615 
Infantile remittent fever {see typhoid fever). 

syphilis (5ee syphilis). 
Inflammation, catarrhal, of larynx, without 
spasm, 63 
with spasm, 69 
of larynx with pseudo-membranous exu- 
dation, 86 
of lungs, 159 
of bronchia, 196 
of pleura, 233 



Inflation, effect of on collapsed lung, and in 
atelectasis, 135, 148 
impossible in pneumonic lung, 166 
in congestion of lung. 166 
Inhalations in treatment of membranous croup, 
105 
of coal gas in hooping-cough, 276 
Injections (5:ee enemata) . 

into cranial cavity in hydrocephalus, 537 
into pleural sac after paracentesis, 251 
in nasal diphtheria, 682 
of air in intussusception, 475 
Inoculability of scarlatina, 698 
Inspection of thorax in pleurisy, 236 
Inspiration, recession of base of thorax in, 42 
Internal convulsions {see convulsions and 

laryngismus). 
Intertrigo (.<(-ft erythema), 879 
Intestines, inflammation of, in measles, 770 

and stomach, general remarks upon 
diseases of, 356 
Intussusception, article on, 462-477 

definition, synonyms, and forms, 462 

frequency, 463 

anatomical appearances, 463 

divisions of. 463 
most frequent seat of, 463 
pathology of, 464 
modes of termination of, 465 
case of elimination of the invaginated 

bowel, 466 
causes of, 466 
mode of production, 467 
symptoms of, 468 
duration of, 471 
modes of termination of, 471 
prognosis in, 471 
diagnosis of, 472 
differential diagnosis of, 473 
treatment of, medical, mechanical, and 

surgical, 475-477 
use of purgatives in, 475 
injections of air and fluids in, 475 
gastrotomy in, 476 
Inunction in scarlatina, 740 

of cod-liver oil in rickets, 869 
in tuberculosis, 857 
Invagination (.^^^-e intussusception), 462 
Invasion of diphtheria often insidious, 667 
of mild eases of scarlatina, 701 
of grave cases of scarlatina, 707, 711 
of measles, 760, 765 
Iodide of potassium {see potassium). 
Iodine, in tubercular meningitis, 499 

as injection in chronic hydrocephalus, 537 
Iron, in laryngismus stridulus, 570 
in infantile paralysis, 630 
in rheumatism, 649 
local use of in diphtheria, 680 
in tuberculosis, 857 

chloride of, with acetic acid, and sp. Min- 
dereri, 420 
in diphtheria, 683 
in scarlatinous angina, 751 
in erysipelas, 889 
iodide of, in pleurisy, 245 

in chronic eczema, 908 
nitrate of, in chronic entero-colitis, 418 
enema of in dysenter\', 446 
Itch (see scabies), 919 

Jacobi, statistics of tracheotomy in croup in 
New York, 117, 119 



INDEX. 



993 



Jacobi, local applicatiotis in diphtheria. 681 
Jenner, recession of base of chest in inspira- 
tion, 41 

on rickets, 862. 864 
Joints, condition of in rheumatism, 647 

affection of, in scarlatina, 729 

Kameela as a vermifuge, 975 
Keratitis, in congenital syphilis, 874 
Kidneys, condition of in diphtheria, 661 

in scarlatinous dropsy, 723 
Kine-pock {see vaccine diseases). 

Laborde. sclerosis of spinal cord in infantile 

palsy, 627 
Lancing gums {see gums). 

Laryngismus, excessive in hooping-cough, 264 
in eclampsia. 545 
in rickets, 865 
stridulus, article on, 557-574 

definition and synonyms, 557 
frequency of, 557 
predisposing causes of, 558 
nature and exciting causes of, 559 
anatomical appearances in, 560 
enlargement of thymus gland in, 560 
centric and eccentric causes of, 563 
symptoms of paroxysm of. 564 
duration and course of, 565 
danger of sudden death in, 565 
other forms of. 565 
holding-breath spells, 566 
diagnosis of. 567 
prognosis in, 567 
treatment of, 568 
importance of lancing gums in, 568 

attention to diet in, 568 
antispasmodics in, 570 
iron in. 570 

treatment of paroxysm, 571 
change of residence in, 571 
illustr.itive cases, 571 
Laryngitis, in scarlatina, 718 
in measles, 769 
in small-pox, 786 
chronic. 65 
pseiido-mfmhraiioiis, 86 

definition, synonyms of, 86 

nature and relations to diphtheria, 86, 

87 
frequency of faucial deposit in, 87, 91 
frequency of, 88 
mortality from, 88 
predisposing causes of, 89 
exciting causes of, 89 
second attacks of, 89 
anatomical lesions in, 90, 91, 92 
extent and characters of false mem- 
branes, 90, 91, 92 
mucous membrane rarely ulcerated, 92 
symptoms of, 93 

of initial stage, 93 
characters of voice and cough, 93, 94 

of respiration, 94 
explanation of recession of base of 

chest in, 95 
expectoration and rejection of fiilse 

membrane in, 95 
negative results of auscultation in, 96. 

115 
mode of recovery in, 97 
duration of, 97 
diagnosis of, 97 



Laryngitis, pseiido-membranoiis, importance of 
examination of throat in, 98 
prognosis in, 98 
treatment of, 99 

bloodletting in, 99 
emetics in, 100 
antimony in, 102 
mercury in, 103 
alkalies in, 103 
opium in, 104 
local treatment in, 104 
inhalations in, 105 
hygienic treatment, 105 
summary of the treatment of, 105 
tracheotomy {see under that head), 
106 
spasmodic, simple, 69-86 
synonyms of, 70 
forms of, 70 
causes of, 70 
anatomical lesions in, 71 
symptoms of, 72 
duration of, 75 
nature of, 75 
diagnosis of from true croup, 76 

from laryngismus stridulus, 567 
peculiarities of voice in, 78 
prognosis in, 79 
treatment of the mild form of, 80 

of the severe form of, 82 
hygienic treatment of, 84 
prophylactic treatment of, 84 
style of dress suitable in, 84 
simple, witiiout spasm, 63 

definition and frequ^cy of, 63 
causes of, 63 
anatomical lesions in, 63 
symptoms and course of, 64 
duration of, 66 
diagnosis of, 66 
prognosis in, 67 
treatment of, 67 
Larynx, general remarks on diseases of, 61 
Legendre and Bailly, researches on collapse of 

lung, 144 
Lichen, article on, 933. 934 

strophulus (56^ strophulus), 931 
tropicus, the variety usually met with, 933 
frequency of, 933 
cause of, 933 
symptoms of, 933 
duration of, 934 
diagnosis of, 934 

of from scabies, 921 
prognosis in, 934 
treatment of, 934 
urticatus {see urticaria), 895 
Liebig, food for infants, 340 
Liver, state of in entero-colitis, 396 
in rickets, 867 
in congenital syphilis, 874 
Lobular pneumonia, in reality collapse of 

lung, 144 
Local applications in chronic coryza, 60 
in membranous croup, 104 
in pneumonia, 192 
in bronchitis, 215 
in pleurisy, 245 
in hooping-cough, 277 
in aphthae, 304 

in ulcero- membranous stomatitis, 308 
in gangrene of the mouth, 317 
in thrush, 343 



63 



994 



INDEX. 



Local applications in diseases of coecum and 
appendix, 461 

of cold in tubercular meningitis, 501 

of cold in simple meningitis, 514 

in eclampsia, 551, 555 

in chorea, 612 

in rheumatism, 650 

in diphtheria, 679 

in mumps, 689 

in congenital syphilis, 876 

to throat in scarlatina, 7;^9, 752 

external in scarlatina, 739 

in erysipelas, 888, 890 

in eczema, 909 

in herpes, 918 

in scabies, 922 

in pemphigus, 925 

in rupia, 928 

in ecthyma, 931 

in strophulus, 932 

in lichen, 934 

prurigo, 935 

in psoriasis, 936 

in pityriasis, 937 

in ichthyosis, 937 

in favus, 946 

in tinea, 951 

in erythema intertrigo, 881 

in alopecia areata, 955 
Locomotor ataxia following diphtheria, 678 
Lotions {see formulee). 

of water in scarlatina, 742, 745 

in treatment of eczema, 909 
Lumbricus {see ascaris lumbricoides). 
Lungs, auscultation of, 42, 43, 44 

general remarks on diseases of, 134 

collnpse and imperfect expansion of, 135- 
158 

inflammation of, 159 

abscess of, following pneumonia, 165 

congestion of, non-inflammatory, 165 

condition of in pleurisy, carnification, 234 

collapse of, in rickets, 867 

tuberculosis of, 843, 849 

percussion of, 43, 45, 46 

condition of, in congenital syphilis, 875 
in typhoid fever, 824, 825, 829 
in sclerema, 959 



Magnesia, hyposulphite of, in scarlatina, 750 
Malarial fever, 690 

causes, frequency of, 690 
symptoms of acute, 690 

features of paroxysm imperfectly devel- 
oped, 691 
of chronic, 691 
enlargement of spleen in, 692 
neuralgia rare in, 692 
diagnosis of, 692 
prognosis in, 692 
treatment of, 692 
quinia in, 692 
iron and arsenic in, 693 
Marsh, F. H , on tracheotomy in croup, 118 
Maturative fever in variola, 787, 799 
Maw-worm (see, ascaris vermicularis). 
Measles {see rubeola), 758 

French {see roseola). 
Meigs, Charles D., treatment of coryza, 58 
use of alum ns an emetic, 101 
on proper position of body in atelectasis 
and cyanosis, 142, 290 



Meigs, Charles D., treatment of paroxysm of 

laryngismus, 571 
Meigs, J. F., case of contraction with rigidity, 
578 
heart-clot in diphtheria. 674 
Membrane, false (see false membrane). 
Meningeal apoplexy (see cerebral hemorrhage), 

519 
Meningitis, simulated by cerebral form of 
pneumonia, 180 
simple, article on. 507-515 

definition, synonyms, frequency, 507 
causes of, 508 
anatomical lesions in, 508 
symptoms of convulsive form, 510 

of phrenitic form, 510 
course and duration of, 511 
diagnosis of, from congestion of brain, 
512 
from tubercular form, 493 
prognosis in, 513 
treatment of, 513 
bleeding in, 513 
calomel in, 514 

cold and counter-irritation in, 514 
tuhercnhii\ article on, 479-507 

definition, synonyms, and frequency, 

479 
predisposing causes of, 480 
exciting causes of, 481 
anatomical lesions in, 481 
microscopical changes in. 481 
division into stages, 485 
mode of invasion, 485 
symptoms of first stage, 486 
hydrencephalic cry, 487 
condition of mind in, 488 
use of ophthalmoscope in, 488 
convulsions in, 489 
circulation in, 489 
symptoms of second stage, 490 
tache meningitique, 491 
nervous symptoms in, 491 
decubitus in, 491 
pulse in, 491 
temperature in. 492 
diagnosis of, from simple meningitis, 
493 
from typhoid fever, 494 
prognosis in, 495 

case of apparent recovery from. 496 
prognosis not absolutely hopeless, 498 
uncertainty of date of death in, 498 
treatment of, 499 
bleeding not to be used, 499 
iodine and iodide of potassium in, 500 
counter-irritation in, 501 
cold applications in, 501 
calomel and mercury in, 502 
prophylaxis in, 502 
narcotics in, 504 
diet in, 504 

importance of country residence, 505 
illustrative case, 506 
Mental condition in rickets, 861 
Mercurial ointment to prevent pitting in vari- 
ola, 803 
in congenital syphilis, 876 
applications in eczema, 913 
in favus, 948 
in tinea, 952 
Mercury (.•(ee calomel). 

in membranous croup, 103 



INDEX. 



995 



Mercury, in pneumonia, 191 
in pleurisy, 244 
in entero-colitis, 407 
in diseases of ececuni and appendix, 461 
in tubercular m^ingitis, 502 
in simple meningitis. 514 
in chronic hydrocephalus, 535 
in scrofula, 841 
in congenital syphilis, 876 
Mesenteric glands, tuberculosis of, 846, 853 
Metastasis in mumps. 688 
Microscopic examination of milk. 341 

of false membranes in diphtheria, 658 
changes in tubercular meningitis. 481 
in spinal cord in tetanus, 586 
in chorea. 598 
in infantile paralysis, 625 
in muscle in infantile paralysis, 623 

in progressive paralysis, 644 
in kidneys in scarlatinous dropsy, 723 
Microsporon furfur, 940 
.Miliary tubercles. 481 
Milk (see also food and diet). 

properties of, and mode of examining 

cow's milk, 332 
mode of preserving, 334 
proper dilution of, for infants, 335 
quantity of. for infants, 335 
preparation of, 338 
human, analysis of, 340 

microscopic examination of, 341 
mode of examining, and properties of, 

341 
substitutes for, 332-337 
Milk-crust {see eczema capitis), 901 
Morbilli {see rubeola), 758 
Mortality {see statistics). 
Mouth, examination of, 47 
mode of examining. 48 
diseases of {see stomatitis), 301 
Mucous membrane, condition in entero-colitis, 
393 
of fauces in diphtheria, 659 
affections of, in congenital syphilis, 872 
of fauces, in scarlatina, 713 
gastro-intestinal, in scarlatina, 730 
eruption on, in small-pox, 786 
condition of, in small-pox, 793 

in cases of ascaris lumbricoides, 966 
Muguet (.se« thrush). 
Mumps, article on, 68.5-690 

definition, synonyms, and frequency of, 

685 
causes of, 686 

anatomical appearances in, 686 
symptoms of, 687 
characters of swelling in, 687 
salivary secretion in, 688 
general symptoms in, 688 
tendency to metastasis in, 688 
prognosis always favorable in, 689 
course and duration of, 689 
usually terminates by resolution, 689 
suppuration of parotid in, 689 
diagnosis of, 689 
treatment of, 689 
danger of febrile sequelae in, 690 
Muriate of ammonia {see ammonia). 
Muriatic acid {seena'x^) 
Murmur, cardiac, in chorea, 596, 601 

cerebral, in rickets, 861 
Muscle, condition of, in atrophic infantile 
paralysis, 623 



Muscle, condition of, in progressive paralysis, 

644 
Muscular sclerosis, progressive {see paralysis), 

634 

Nasal variety of diphtheria, 665 
Nature of spasmodic laryngitis, 75 

of pseudo-membranous laryngitis and 
diphtheria, 86 

of collapse of the lung, 144 

of pneumonia, 159 

of emphysema, 220 

of pneumothorax, 253 

of hooping-cough, 269 

of cyanosis, 286 

of aphtbje. 392 

of thrush. 323. 329 

of tonsillitis. 346 

of simple diarrhoea, 367 

of gastritis, 377 

of entero-colitis, 397 

of cholera infantum, 426 

of diseases of coecum and appendix, 447, 
448, 452 

of cerebral congestion, 517 

of chronic hydrocephalus, 528 

of eclampsia, 545 

of laryngismus stridulus, 559 

of contraction with rigidity, 575 

of chorea, 602 

of atrophic infantile paralysis, 623 

of progressive muscular sclerosis, 643 

of diphtheria. 656 

of mumps, 686 

of rickets, 868 

of scarlatina, 697 

of rubeola, 758 

of variola, 783 

of varicella, 819 

of typhoid fever, 823 

of erysipelas, 884 

of herpes iris, 917 

of scabies, 919 

of prurigo, 934 

of parasitic skin diseases, 938 

of favus, 944 

of alopecia areata. 95^^ 
Nephritis, after scarlatina, 721-728 
Nervous system, general remarks on diseases 
of, 478 

symptoms (see cerebral symptoms). 
Nettle-rash (see urticaria), 894 
Neurosis, evidence in favor of hooping-cough 
being a. 269 
of laryngismus stridulus 
being a, 559 

infantile paralysis not a, 624 
Niemeyer, indications for bleeding in pneu- 
monia, 189 

on lesions in catarrh of stomach, 379 

Obstruction of the intestines {see intussuseep-* 

tion), 462 
Occipital bone, depression of, as cause of teta- 
nus, 583 
(Edema of face in bronchial phthisis, 847 

of neck in scarlatina, 714 

in variola, 787 

in typhoid fever, 831 

in erysipelas, 8S6 

in scleretxia, 957 
Ogle, J. W.. on chorea, 592 
Oidium albicans {.>~ee thrush), 321 



INDEX. 



Ointments (5(?<? local applicatians). 

in treatment of seat-worms, 978 
Omentum, tuberculosis of, 845 
Ophthalmia, in variola, 800 
Ophthalmoscope in tubercular meningitis, 488 
Opisthotonos in tetanus nascentium, 587 
Opium in catarrhal croup, 82, 84 

in membranous croup, 104 

in pneumonia, doses, and mode of admin- 
isterincf, 194 

in pleurisy, 243 

in thrush, 343 

in entero-colitig, 409 

in cholera infantum, 437 

in dysentery, 445 

in diseases of eoecum and appendix, 461 

in eclampsia, 554 

in rheumatism, 650 

in variola, 799 

in typhoid fever, 835 
Otorrhoea, in scarlatina, 715, 729 
Ova of acarus scabiei, 920 
Oxyuris vermicularis [see ascaris vermicularis), 
962 

Pacliing, cold, in scarlatina, 749 
Pain, modes of expressing, 22 

in pneumonia, seats and peculiarities of, 

169, 178 
in pleurisy, seats and peculiarities of, 237 
abdominal, in intussusception, 469 
in tuberculous peritonitis, 852 
in variola, 784 
Palpation, of thorax in pleurisy, 237 
Pancoast, J., on tracheotomy in croup, 111, 

120 
Papules, chapter on, 931 

in small-pox, 784 
Paracentesis, in pleurisy {see pleurisy), 246- 
253 
in hydrocephalus, 536 
Paralysis, in tubercular meningitis, 491 
in cerebral hemorrhage, 624, 627 
in chorea-, 601 
in diphtheria, 675 
after scarlatina, 729 
atrophic iiifundle, article on, 615-633 
history of and authors on, 616 
synonyms of, 617 
causes of, 617 

forms of and muscles affected in, 619 
mode of attack. 618 
reaches its maximum suddenly, 619 
condition of paralyzed muscles in, 

620 
illustrative case of, 620 
at times temporary, 620 
at other times followed by atrophy, 

620 
temperature lowered in palsied parts, 

621 
subsequent deformities in, 621 
duration of, 622 
prognosis in, 622 
electrical condition of muscles as aid 

in prognosis, 623 
microscopic examination of muscles 

in, 623 
anatomical lesions in and nature of, 

623 
cannot be considered reflex, 624 
primary condition usually one of spi- 
nal congestion, 625 



Paralysis, atrophic in fa.yuile, sclerosis of cord in 
a later stage, 626 
other lesions of cord occasionally met 

with, 627 
diagnosis of from other forms of pa- 
ralysis, 628 
from progressive muscular atro- 
phy, 628 
occasionally simulates coxalgia, 629 
use of local treatment to spine in. 629 
ergot, belladonna, and iodide of po- 
tassium in acute stage, 629 
iron and strychnia in later stage, 630 
use of electricity in, directions for 

choice of current, 630 
mechanical contrivances in treatment 

of, 631 
tenotomy to relieve deformity, 632 
necessity of pursuing treatment for 
years, 633 
facial, article on, 633, 634 
causes of, 633 
symptoms of. 633 
diagnosis of from cerebral hemiplegia, 

633 
prognosis in, 634 
treatment of, 634 
progressi've, with apparent hypertrophy of 
the muscles {see progressive muscu- 
lar sclerosis). 634-645 
Parasite of thrush {see oidium albicans). 

of favus {see achorion Schoenleinii). 939 
of tinea tricophy tina {see tricophyton) , 939 
of tinea versicolor (5f« microsporon), 940 
of alopecia areata, 940 
Parasitic skin diseases, 937-995 
general remarks on, 937 
varieties of. 937 
nature of, 938 

mode of detecting fungus in, 938 
relation between fungus and the eruption, 

938 
description of achorion Schoenleinii {see 

favus also), 939 
description of tricophyton \^see tinea also) , 

939 
description of microsporon furfur {see alo- 
pecia areata) , 940 
relation of the various fungi in, 940 
Parasiticides. 947 
Parotid gland, condition of in mumps, 687 

suppuration of in mumps, 688 
Parotitis {see mumps). 

in typhoid fever, 830 
Paroxysm of hooping-cough, peculiarities of, 
261 
treatment of, 280 
of laryngismus stridulus, symptoms of, 564 

treatment of, 571 
of eclampsia, symptoms of, 542 

treatment of, 551 
in tetanus, 587 
in diphtheritic croup, 665 
Parrot, on thrush, 323, 326 
Pelvis, alterations of in rickets, 864 
Pemphigus infantilis {see rupia escharotiea). 
Pemphigus, in congenital syphilis, 872, 924 
article on, 923-925 
definition and synonyms of, 923 
forms and frequency of, 923 
causes of. 924 
symptoms of, 924 
duration of, 924 



INDEX. 



997 



Pemphign?, dingnosi? of, 925 
prognosis in, 925 
general tre;itment of, 925 
local treatment of, 925 
Pepper, Prof, case of laryngismus stridulus, 
573 
incontinence of urine in chorea, fiOO 
Pericarditis, acute, symptoms and difficulty of 
detection of, 291 
prognosis in, 291 
anatomical appearances in, 292 
treatment of, 292 
chronic, 292 
Percussion of heart, 36 

of lungs, mode of performing, &Q., 43,45,46 
in pneumonia, 170, 177 
in pleurisy, 236 
in bronchial phthisis, 848 
in pulmonary phthi^is, 851 
Perforation of ccecum, 457 
of appendix coeci. 457 
of intestine in typhoid fever, 830, 834 
from ascaris lumbricoides, 966 
Peritoneum, tuberculosis of {spc tuberculosis), 

844, 852 
Peritonitis, from perforation of coecum and ap- 
pendix. 454 
tuberculous (^^f? tuberculosis), 844, 852 
in scarlatina, 729 
Perityphlitis, in art. on dis. of coecum and ap- 
pendix, 447-462 
definiiion, 448 
iliac abscess in, 449 
anatomical appearances in, 452 
symptoms of, 457 
Perspiration, tendency to profuse, in rickets, 

861 
Pertussis (.«^p hooping-cough), 259 
Pharyngitis, simple. 348-353 

definition and frequency', 348 
causes of, 348 
lesions in, 349 
symptoms of, 349 
diagnosis of, 351 
prognosis in, 352 
treatment of, 352 
Phlyzacia {sff ecthyma), 929 
Phthisis (5e« tuberculosis). 
Physical signs {see auscultation and percus- 
sion) . 
Physiognomy in diseases, 21 
in pneumonia, 169 
in pleurisy, 237 
in tetanus, 587 
in cases of worms, 968 
Pinkroot as a vermifuge, 973 
Pitting in variola [see under variola), 788 
in varioloiil, 792 
treatment to prevent, 801 
Pityriasis, sj-mptoms of, 937 

treatment of, 937 
Pleurisy, article on. 233-253 

definition, frequency, and forms, 233 
piedi.-posing causes of, 233 
exciting causes of, 233 
anatomical lei^ions in, 234 
symyitoms of acute form, 235 
physical signs from auscultation, 235 
percussion, 236 
inspection, 236 
palpation, 237 
rational sjmptoins, pain, cough, respira- 
tion, pulse, 237 



Pleurisy, urine in, 239 

symptoms of chronic form, 239 

of empyema, 240 
diagnosis of, 241 
obscurity in early stage from violence of 

constitutional symptoms, 242 
prognosis and mortality in, 243 
treatment of, 243-253 
bloodletting in, 243 
antimony in, 243 
mercury in, 244 

diuretics and purgatives in, 245 
external remedies in, 245 
paracentesis, 246-253 

indications for, 246 

objections to, 246 

Trousseau's rule in regard to, 247 

indicated in empyema, 248 

success greater in children, 248 

rules to guide in advising, 249 

mode of performing, 249 

after treatment, 250 

use of medicated injections through 
canula, 251 
illustrative ease of chronic form, 252 
Pleuro pneumonia, physical signs in, 236 

mortality in, 243 
Pneumonia, lobular, in reality collapse of the 
lung, 144 
differences between condition of lung in, 

and in collapse, 146 
in hooping-cough, 266 
in measles, 768 
article on, 159-196 
definition and synonyms of, 159 
frequency and mortality of, 159 
forms and classification, 159, 160 
hAidfir. identity of with collapse, 144, 160 
predisposing causes, 161 
age at which most frequent. 161 
table showing influence of season, 162 
relation of mortality from, to the temper- 
ature, 163 
exciting causes of, 163 
anatomical lesions of, 163 

of lobular form, 163 

of partial form, 164 
abscess of lung following. 165 
diff'erence between condition of lung in, 
and in non- inflammatory congestion, 
165 
inflation of lung impossible in, 166 
usually unilateral, 166 
portion of lung involved in, 166 
apex quite frequently the seat of, 167 
not so frequently attended by bronchitis 

as formerly thought, 167 
association with pleurisy, 168 

with emphysema, 168 
general course of, in young children, W8 

in children over two years old, 172 
varieties of mode of onset, simulating 

other affections, 172 
unfavorable symptoms and modes of death, 

174 
general course of the partial form, 175 
duration of, 176 
physical signs of, 176 
cough in, 177 
expectoration in, 178 
thoracic pain in. 169, 178 
state of respiration in, 169, 179 
physiognomy in, 179 



998 



INDEX. 



Pneumonia, grade of fever in, 170, 180 
rate of pulse in, 170, 173, 179 
nervous symptoms, convulsions, 180 
appetite, vomiting, diarrhoea in, 181 
thirst in, 181 

urine; albuminuria in, 181 
chlorides in, 181 
diagnosis from bronchitis, 182 
from pleurisy, 182 
of partial form, 182 
of cerebral form, 183 
daring teething, 184 
from typhoid fever, 832 
prognosis of, 185 
treatment of, 186-196 

question of bloodletting in treatment of, 187 
indications for bleeding in, 189 
use of antimony in, 190 
calomel in, 191 
salines in, 191 
muriate of ammonia in, 191 
quinia in, 191 
ipecacuanha in, 191 
purgatives in, 192 
external applications in, 192 
tonics and stimulants in, 193 
diet in, 193 
use of opium in, 194 
general management of, 195 
diet in, 195 

importance of administration of water in, 
195 
confinement to bed, 196 
change of position in, 196 
scrofulous, 838 
relations of to tuberculosis of the lungs, 

842, 851 
in typhoid fever, 830 
Pneumothorax, from rupture of abscess of the 
lung, 165 
article on, 253 
nature of, 253 

anatomical appearances in, 254 
case of, 255 
causes of, 256 

phthisisj pneumonia, gangrene, and 
emphysema, 256 
symptoms of, 257 
course of, 258 
prognosis in, 258 
diagnosis of, 258 
treatment of, 258 
Pock, anatomy of variolous, 794 

of vaccine, 805 
Pompholyx {see pemphigus), 923 
Porrigo {see tinea), 948 
Porrigo larvalis (see eczema capitis), 901 

granulata {see eczema, granulatum), 904 
favosa {.see favus), 942 
scutulata {see favus), 943 
Position recommended in atelectasis, 142 
Post-pharyngeal abscess (seeretro-pharyngeal), 

354 
Potash, carbonate of, in hooping-cough, 274 
and acetate of, in rheumatism, 649 
chlorate of, in ulcerative stomatitis, 308 
in diphtheria, 683 
in scarlatina, 739, 752 
caustic solutions of, in eczema, 911 
Potassium, bromide of, in eclampsia, 655 
iodide of, in pleurisy, 244 

in chronic valvular disease of the 
heart, 300 



Potassium, iodide of, in tubercular menin- 
gitis, 499 
in chronic hydrocephalus, 535 
in infantile par;i lysis, 629 
in rheumatism, 649 
in scrofula, 841 
in congenital syphilis, 876 

sulphuret of, baths of, in chorea, 612 
Poultices in pneumonia, 193 

in bronchitis, 215 

in eczema, 9 10 

in favus, 946 
Prickly-heat {see lichen tropicus), 933 
Prognosis in simple laryngitis without spasm, 67 

in spasmodic simple laryngitis, 79 

in pseudo-membranous laryngitis, 98 

in atelectasis pulmonum, 141 

in collapse of the lung, 156 

in pneumonia, 185 

in bronchitis, 212 

in emphysema, 229 

in pleurisy, 243 

in pneumothorax, 258 

in hooping-cough, 268 

in acute pericarditis, 291 

in acute endocarditis, 293 

in chronic valvular disease of the heart, 
295, 296, 297 

in aphthge, 304 

in ulcerative stomatitis, 307 

in gangrene of the mouth, 316 

in thrush, 330 

in tonsillitis, 345 

in chronic enlargement of tonsils, 347 

in simple pharyngitis, 352 

in retro-pharyngeal abscess, 355 

in indigestion, 361 

in simple diarrhoea, 373 

in gastritis, 382 

in entero-colitis, 402 

in cholera infantum, 433 

in dj'Sentery, 444 

in diseases of coecum and appendix, 458 

in intussusception, 471 

in tubercular meningitis, 495 

in simple meningitis, 513 

in cerebral hemorrhage, 526 

in chronic hydrocephalus, 534 

in eclampsia, 549 

in laryngismus stridulus, 567 

in contraction with rigidity, 577 

in tetanus, 588 

in chorea, 606 

in atrophic infantile pai-alysis, 622 

in facial paralysis, 634 

in progressive muscular sclerosis, 642 
• in acute rheumatism, 648 

in diphtheria, 670 

in diphtheritic paralysis, 677 

in mumps, 689 

in malarial fever, 692 

in rickets, 865 

in tuberculosis, 865 

in congenital syphilis, 875 

in scarlatinous dropsy, 728 

in scarlatina, 733 

in rubeola, 774 

in variola, 797 

in varioloid, 797 

in varicella, 821 

in typhoid fever, 832 

in scrofula, 840 

in erythema, 881 



INDEX 



999 



Prognosis in erysipelas, 887 
in roseola, S94 
in urticaria, 897 
in eczematous affections, 90o 
in herpes, 917 
in scabies, 922 
in pemphisus, 925 
in rupia, 928 
in ecthyma, 930 
in strophulus, 932 
in lichen, 93-t 
in prurigo, 935 
in favus, 945 
in tinea, 950, 951 
in alopecia areata, 955 
in sclerema, 958 
in ascaris lumbricoides, 971 
in ascaris vermicularis, 977 
Progressive muscular sclerosis, article on, 634- 
645 
definition of, 634 
history and synonyms of, 635 
causes of, 635 
symptoms of, 636 
peculiar gait in, 636 
condition of muscles in, 636 
produces club-foot, 637 
electrical condition of muscles in, 637 
appearance of skin in, 638 
temperature in, 638 
case of, 638 

mental condition in, 642 
duration variable, 642 
termination fatal, by affection of re- 
spiratory muscles, 642 
diagnosis of, 642 
anatomical appearances in, 643 
treatment of, (i45 
Prurigo, article on, 934 
definition of, 934 
frequency of. 934 
causes of, 934 
symptoms of. 935 
duration of, 935 
diagnosis of, from strophulus or lichen, 935 

from scabies, 921 
prognosis in, 935 
treatment of, 935 
Pseudo-hypertrophic muscular paralysis {see 

progressive muscular sclerosis), 634-645 
Pseudo-membranous angina {see. diphtheria), 
651 
in true croup, 90 
laryngitis {see laryngitis) 
Psoriasis, diffusa, symptoms of, 936 
guttata, symptoms of, 936 
treatment of, 936 
Pulmonary resonance, characters of, in chil- 
dren, 45 
tuberculosis, 843, 851 
Pulse, in children, 33, 34, 35 

rate of, at different ages, 33, 34 
intermittence or irregularity of, 35 
irritability of, 35 
to be examined during sleep, 33 
peculiarities of, in tubercular meningitis, 

489, 491 
in mild cases of scarlatina, 703 
in grave cases of scarlatina, 710 
in variola, 787 
in typhoid fever, 829 
Purgatives {see formulae) in pleurisy, 245 
in diseases of coecum, 460 



Purgatives in intussusception, 475 

in eclampsia, 552 

in chorea, 608 

in rheumatism, 650 

in scarlatina, 739, 756 

in scarlatinous dropsy, 756 

in rubeola, 777 

in variola, 799 

in eczema, 907 

in worms, 972 
Pustules in variola, 785 

chapter on, 929 

Quinia in pneumonia, 193 

in bronchitis, 217 

in entero- colitis, 412 

in tetanus, 590 

in rheumatism, 650 

in diphtheria, 683 

in malarial fever, 692 

in variola, 799 

in typhoid fever, 834 
Quinsy (spe tonsillitis), 344 

Rachitis {see rickets) . 

Radcliffe, J. N., electrical condition of mus 

cles in infantile paralysis, 623 
Rashes, 878 

RavF meat, use of, in entero-colitis, 415 
Reaction of cow's and human milk, 232, 241 
Recession of base of chest in inspiration, 41 
Rees, G. A., recession of base of chest in inspi- 
ration, 42 
respiration in collapse of the lung, 138 
Reflex irritability exaggerated in early stage 

of pleurisy, 242 
Relapses of chorea, 602 

of acute rheumatism, 647 
of typhoid fever, 826 
Remittent Fever {see typhoid fever) 
Residence, change of, in laryngismus stridulus, 
671 
in unhealthy localities, influence of, 403 
change of, in treatment of entero-colitis, 

403 
in country, importance of, 403 
Resonance, pulmonary, character in children, 45 
Respirations, general characters of, in chil- 
dren, 39, 40, 41, 44 
rate of, 40 
expiratory, 41 
diagnostic signs from, 41 
peculiar in atelectasis and croup, reces- 
sion of base of thorax, 41, 95, 138 
puerile, 44 

alteration of, in simple laryngitis, 64 
in catarrhal croup, 79 
in true'croup, 94 
in pneumonia, 168, 179 
in bronchitis, 209 
in pleurisy, 238 
in bronchial phthisis, 847 
in typhoid fever, 824, 825,. 829 
in sclerema, 957 
Respiratory muscles affected in some cases of 
chorea, 600 
organs, diseases of, 52 
sounds, 44 
Rest, importance of, in cholera infantum, 439 
in bed, importance of, in rheumatism, 651 
Retro-pharyngeal abscess, 354 

definition, causes, symptoms of, 354 
diagnosis, prognosis, treatment of, 355 



1000 



INDEX. 



Return-cry, alteration of. 27 
Revaccination, 816 
Rhagades in congenital syphilis, 873 
Rheumatism as a cause of heart disease, 291 
of chorea, 593 
in scarlatina, 729, 754 
acute, article on, 646-651 
symptoms of, 646 
temperature in, 647 
condition of joints in, 647 
local symptoms often comparatively 

slight, 647 
duration and tendency to relapses, 

647 
causes of, 647 
influence of sex not yet determined, 

648 
chorea as complication of, 593 
heart disease as complication of, 290 
prognosis in. 648 

diagnosis diflBcult when local symp- 
toms are slight, 648 
treatment of, 649 
alkalies in, 649 
iron and quinia in, 649 
opium in, 650 
local applications in, 650 
importance of strict rest in bed, 651 
diet in, 651 

treatment of complications, 651 
Richardson, B. W., heart-clot in diphtheria, 

674 
Rickets, article on, 858-870 

frequency of, in England and America, 858 
bibliography of, 859 
causes of, 859 

symptoms of initiatory stage, 860 
digestive disturbances in, 860 
general soreness of body in, 861 
tendency to profuse perspiration in, 861 
dentition impeded in, 861 
urine in, 861 
mental condition in, 861 
cerebral blowing murmur in, 861 
stage of deformity, 862 
alterations of long bones in, 862 
of head in, 862 
of spine in, 863 
of thorax in, 863 

of thorax due to atmospheric pres- 
sure, 864 
of pelvis in, 864 
general symptoms in later stage, 864 

in favorable cases, 864 
secondary diseases causing death in, 865 
prognosis and duration in, 865 
diagnosis of, 865 

morbid anatomy of bones in, 866 
collapse of lung in, 867 
condition of viscera in, 867 
pathology of, 868 
treatment of, 869 
importance of proper diet in, 869 
codliver oil in. 869 
means of avoiding deformities, 870 
Rilliet and Barthez, size of heart by percus- 
sion, 37 
diagnosis between true and false 

croup. 77 
atelectasis and collapse of the lung, 

145 
state of vessels in gangrene of the 
mouth, 311 



Rilliet and Barthez, diagnosis of gangrene of 

the mouth from ulcero-membran- 

ous stomatitis, 315 

lesions in diarrhoea, 369 

on pathology of cholera infantum, 428 

diagnosis of simple from tubercular 

meningitis, 493 
diagnosis of simple meningitis from 

congestion of the brain, 512 
diagnosis of symptomatic from essen- 
tial contraction, 577 
j on convulsions in scarlatina, 735 

cold affusion in scarlatina, 743 
Ringworm (see tinea), 948 
I Robinson, on heart-clot in diphtheria, 675 
Roger, pulse in children, 34 
respiration in children, 40 
and Barth, auscultation in croup, 96 
Rokitansky, on changes in spinal cord in teta- 
nus, 586 . 
Rosalia, or rubeola notha, 733 
Roseola, epidemic, or rubeola notha, 733 
article on, 891-894 
definition and synonyms, 891 
frequency of, 891 
forms of, 891 

causes : occasionally epidemic, 891 
symptoms of ; eruption, 892 
duration of, 892 
anmilata. 

symptoms of, 893 
diagnosis of, from scarlatina, 893 
from rubeola, 894 
from herpes iris, 917 
prognosis in, 894 
treatment of, 894 
Round--worm {see ascaris lumbricoides), 961 
Rubeola, article on, 758-781 
definition of, 758 
forms of, 758 
frequency of, 694, 758 
epidemic nature of, 758 
contagiousness of, 758 
period of incubation of, 759 
influence of age on frequency of, 759 
straw-fungus as cause of, 759 
mode of invasion of regular form of, 760 
fever in initial stage of, 760 
catarrhal symptoms in initial stage of, 761 
marked drowsiness in initial stage of, 761 
convulsions in initial stage of, 761 
red papules on palate in initial stage of, 762 
duration of initial stage of, 762 
date of appearance of eruption in, 763 
characters of eruption in, 763 
symptoms during eruption in, 763 
duration of eruption in, 764 
urine during eruption in, 764 
symptoms of stage of decline of, 764 
desquamation in, 764 
temperature in, 765 
irregularities of prodromic stage in, 765 

of eruption, 765 
petechial character of eruption without 

any malignant symptoms, 766 
form of, without eruption, 766 
/lot ha or sine catarrho, a form of roseola, 

766 
malignant form of, 767 

eruption in, 767 
complications and sequela? of. 767-772 
bronchitis and pneumonia in, 768 

effect of upon eruption, 768 



INDEX. 



1001 



Rubeola, prognosis in bronchitis and pneumo- 
nia in, 769 
laryngitis in, 769 
enteritis in, 770 

frequency of, 770 

causes of, 770 

symptoms of, 770 
fatal cerebral symptoms in, 771 
cases of, 771 
serous effusions in, 771 
tendency of, to develop tuberculosis, 772 
coexisting with variola, scarlatina, or 

erysipelas, 772 
anatomical lesions in, 772 
diagnosis of, 773 

from roseola, 773, 894 

from variola, 773 

from typhus, 774 
prognosis in, 774 
causes of death in, 775 
hygienic treatment of, 776 
diet in, 776 

laxatives and febrifuges in, 777 
depletion in, 778 
treatment of malignant form of, 778 

of pulmonary complications in, 779 
counter-irritation in pulmonary complica- 
tions in. 779 
treatment of diarrhoea in, 780 

of laryngitis in, 780 

of cerebral symptoms in, 780 
Rupia, article on, 926-928 
definition of, 926 
varieties of, 926 
causes of, 926 
symptoms of, 926 

diagnosis of, from pemphigus, 927 

from ecthyma, 927 
prognosis in, 928 
general treatment of. 928 
local treatment of, 928 
simp/ex. 

symptoms of, 926 
promiiieHS. 

symptoms of, 926 
esdiarotica. 

symptoms of, 927 

Salines, in treatment of membranous croup, 103 

of pneumonia, 192 
Salisbury, on straw fungus as cause of mea- 
sles, 759 
Salivary secretion in mumps, 688 
Santonin as a vermifuge, 974 
Scabies, article on, 919-923 
definition of, 919 
caused by acarus scabiei, 919 
seat of eruption in, 919 
local symptoms in, 919 
character of eruption in, 919 
cuniculi in, 920 
mode of detecting acarus, 920 
general symptoms of, 920 
description of the acarus, 920 
diagnosis of, by finding acarus or its ova, 
920 
from eczema simplex, 905, 921 
from prurigo, 921 
from lichen, 921 
prognosis in, 922 
treatment of, 922 

applications of sulphur in {see formulas), 
922 



Scabies, substitutes for sulphur in, 922 

tarry applications in, 922 

carbolic acid in, 923 

general treatment of, 923 
Scarlatina, article on, 694-758 

definition of, 694 

frequency of, 694 

forms of, 695 

contagion as a cause of, 697 

period of incubation of, 698 

transmitted by fomites, 698 

inoculability of, 698 

epidemic nature of, 698 

occasional occurrence of second attacks 
of, 699 

influence of age upon frequency of, 699 
of sex upon, 700 

symptoms of mild cases of, 701-706 

invasion generally sudden in, 701 

occasionally a short prodromic stage, 702 

characters of eruption in, 702 

duration of eruption in, 703 

pulse and fever in stage of eruption, 703 

tongue in stage of eruption, 704 

urine in stage of eruption, 704 

fauces in stage of eruption, 704 

symptoms of decline of, 705 

desquamation in, 705 

duration of mild cases, 705 

temperature in, 705 

no sharp line between mild and grave 
cases, 706 

symptoms of grave cases of, 707-721 

sudden invasion in ataxic form of, 707 

ease of, 707 

general symptoms in ataxic form of, 710 

convulsions in ataxic form of, 710 

delusive improvement in ataxic form of, 
710 

eruption in ataxic form of, 711 

fatal symptoms in at;ixic form of, 711 

invasion of grave cases sometimes less 
sudden, 71 1 

condition of fauces in grave cases, 713 

pseudo-membrane in, 713 

swelling of submaxillary and cervical 
glands in grave cases, 714 

coryza and otorrhoe a in grave cases, 715 

eruption in grave cases, 715 

general symptoms in grave cases, 716 

cases of this grave form, 716 

laryngitis in grave form, 718 

duration of grave form, 721 

complications and sequelae of, 721-729 

dropsy as a sequel of, 721-728 

preceded by albuminuria, 721 
frequency of, very variable, 722 
period of occurrence, 722 
usually due to cold, 722 
due to tubal neplirilis. 723 
condition of kidneys in, 723 
preceded by febrile symptoms, 724 
seat of effusion in, 725, 727 
course and dui;ition of, 725 
modes of denth in, 725 
urEomic symptoms in. 725 
urine greatly di.ninished in, 726 

characters of. in, 727 
prognosis in, 72S 
uraemia not necessarily fatal, 728 

diarrhoea as a complication of, 728 

rheumatism during. 729 

inflammation of serous membranes in, 729 



1002 



INDEX. 



Scarlatina, endo- or pericarditis in, 729 
peritonitis in, 729 

complicated with variola, measles, or diph- 
theria, 729 
paralysis after, 729 
anatomical lesions in, 729 
condition of gastro-intestinal mucous 
membrane in, 730 

of skin in, 730 

of blood in, 730 
connection of, with enteric fever, 730 
heart-clot in, 731 
diagnosis of from measles, 732 

from roseola, 733, 893 

from diphtheria, 671, 733 

from rubeola notha, 733 

from erythema fugax, 879 
prognosis in, very variable in different 
epidemics, 733 

in mild cases, 734 

in grave cases, 735 
grave significance of convulsions in, 735 
unfavorable symptoms in, 737 
favorable symptoms in, 737 
hygienic treatment of, 737 
diet in, 739 

treatment of mild cases, 738-741 
use of warm baths and affusion in mild 

cases, 739 
care in use of purgatives in mild cases, 

739 
treatment of angina in mild cases, 739 
inunction in, 740 
treatment of grave cases, 741-754 

cold affusions in grave cases, 742 
general remarks on baths, lotions, and 

affusions in grave cases, 745 
guide as to using cold in, 747 
best method of applying, 749 
temperature likely to continue to fall after 

application of, 749 
hyposulphite of soda and magnesia in, 

750 
use of tonics and stimulants in grave cases, 

751 
treatment of angina in grave cases, 752 
external use of ice in grave cases, 752 
case of, 753 
importance of removing viscid secretions 

from throat, 753 
diarrhoea in, 754 
treatment of the rheumatism in, 754 

of otorrhoea, 754 

prophylactic of dropsy, 754 

of mild cases of dropsy, 756 

of severe cases of dropsy, 756 
diuretics in, 756 

hot baths as diaphoretics in dropsy, 756 
treatment of cerebral symptoms in dropsy, 
757 

of the later stages of dropsy, 757 
use of belladonna as a prophylactic in, 757 
Sclerema, article on, 956-960 

definition and synonyms of, 956 

frequency of, 956 

date of occurrence of, 956 

causes of, 956 

atelectasis as cause of, 956 

extent of, 957 

condition of skin in, 957 

oedema in, 957 

temperature in, 957 

peculiar cry in, 957 



Sclerema, general symptoms of, 957 
symptoms of in later life, 958 
prognosis in, 958 
diagnosis of, 958 
anatomical appearances, 958 
condition of skin in, 958 
bloodvessels in, 959 
lungs in, 959 
treatment of, 959 
j Sclerosis of spinal cord in infantile paralysis, 
626 
progressive muscular, 634 
Scrofula as sequel of hooping-cough, 267 
article on, 836-842 
definition and characters of, 836 
associated with tuberculosis, 836 
causes of, 837 
symptoms of, 837 
stages of, 838 

pneumonia and bronchitis in, 838 
albuminoid degeneration of viscera in, 839 
anatomical appearances in, 840 
diagnosis of, 840 
prognosis in, 840 
treatment of, 840 

preventive of, 840 
iodine preparations in, 841 
mercury in. 841 
arsenic in, 842 
Season, influence upon frequency of true croup, 
89, 655 
pneumonia and bronchitis, 162 
diphtheria and croup, 655 
Seaton, E. C, on vaccination, 815 
Seat- worm {see, ascaris vermicularis), 962 
Second attacks of scarlatina, 699 
Secondary fever in variola, 787, 799 
See, on gymnastic exercises in chorea, 613 
Sensibility affected in diphtheritic paralysis, 

677 
Shingles {^see, herpes zoster), 915 
Sims. Marion, on cause of tetanus nascentium, 

583 
Silver, nitrate of, in chronic entero-colitis, 417 
in dysentery, 446 

local application of in diphtheria, 679 
in diphtheritic paralysis, 685 
local use of in scarlatinous angina, 
753 
to prevent pitting in variola, 801 
enema of, in worms, 978 
Skin, diseases of, general remarks on, 877 
examination of, 30, 31, 32 
color of, in infants, 30, 31 

in different diseases, 31 
exudation on, in diphtheria, 660, 665 
in congenital syphilis, 871 
in scarlatina (see eruption and desquama- 
tion), 
in measles {see eruption and desquama- 
tion). 
in variola {see. eruption and desquama- 
tion). 
in typhoid fever, 827 
gangrene of, in erysipelas, 886 
in sclerema, 957 
Sleep, diagnostic signs from, 23 
Small-pox (see variola) , 781 
Smith, J. Lewis, on lesions in cyanosis, 283 
on symptoms in cyanosis, 287 
state of intestine in entero-colitis, 392 
on liver in entero-colitis, 396 
Snufiies, 52 



INDEX. 



1003 



Soap? in treatment of eczema, 912 
Soda, hyposulphite of, in scarlatina, 750 

* in favus, 947 
Softening of stomach, 380 

of bones in rickets. 862 
Soreness of bod}- in rickets, 861 
Sounds of heart, 36 
respiratory, 44 
Spasm of glottis {see laryngismus stridulus) 
557 
carpo pedal, 565, 576 
Spence, J., on tracheotomy in croup, 112 
Sphincters affected in chorea, 600 
Spigelia as vermifuge, 973 
Spinal cord in tetanus, 586 
in chorea, 597 
in infantile paralysis, 625 
column, alteration of, in rickets, 863 
Spiritus saponatus kalinus, 912 
Spleen, enlarged in typhoid fever, 828 
Squamte. chapter on, 936 
rare in children, 936 
Statistics of frequency and mortality of pneu 
monia, 159, 162, 185 
of bronchitis, 162, 197 
ofpleuris}', 243 

after paracentesis in pleurisy, 248 
of true croup, 88, 653, 655 
after tracheotomy in true croup, 106- I 
118 . ' 

of hooping-cough, 260, 268 
of thrush, 330 
of entero colitis, 386 
of cholera infantum, 386, 442 
of nervous diseases, 479 
of tubercular meningitis, 489 
of eclampsia, 538, 549 
of laryngismus stridulus, 567 
of tetanus nascentium, 584 
of chorea, 691, 606 
of diphtheria as compared with true 

croup, 88, 663, 655 
of rickets, 858 
of scarlatina, 694, 700, 734 
of rubeola. 694, 758 
of variola, 782 

of variola after vaccination, 815, 818 
of typhoid fever, 832 
of pulmonary tuberculosis, 843, 844 
Stimulus, indications for, in pneumonia, 193 
use of, in entero-colitis, 412 

in stage of collapse in cholera infan- 
tum, 437 
in chorea, 611 
in diphtheria, 684 
in scarlatina, 752 
in variola, 799 
in typhoid fever, 835 
in erysipelas, 890 
Stomach and intestines, general remarks on 
diseases of, 356 
functional disease of (see indigestion), 

356 
diseases of, attended with lesions, 
377 
inflammation of (see gastritis), 377 
condition in entero-cnlitis, 396 
eruption on, in variola, 793 
Stomatitis . 

in congenital syphilis, 873 
in small-pox, 786 
eryt/i emulous. 
article on, 301 



Stomatitis, e'7jthP7natous, definition and fre- 
quency of, 301 

causes of, 302 

symptoms of, 302 

treatment of, 302 
follicular. 

article on, 302-305 

definition, synonyms, frequency of, 302 

forms of, 303 

causes of, 303 

symptoms and duration of, 303 

diagnosis of, 303 

prognosis in, 304 

treatment of, 304 
ulcerative or ulcero-memhranoiis. 

article on, 305-309 

definition, sj^nonyms, frequency of, 305 

causes of, 305 

symptoms and course of, 306 

duration of, 306 

diagnosis of, 307 

prognosis in, 307 

treatment of, 307 
gangrenous. 

ar'ticle on, 309-321 

definition, synonyms, frequency of, 309 

causes of, 310 

anatomical lesions of, 310 

symptoms and course of, 312 

duration of, 314 

complications of, 314 

diagnosis of, 316 

prognosis in, 316 

treatment of, 316 
Stools, diagnostic signs from the, 50 

in simple diarrhoei, 372 

in acule entero-colitis. 398 

in chronic entero-colitis, 402 

in cholera infantum, 430 

bloody, in intussusception. 468 

in typhoid fever, 825, 826, 828 

in case of worms, 969 
Straw-fungus as cause of rubeola, 759 
Strophulus. 

article on, 931-933 

definition of, 931 

causes of, 931 

varieties and symptoms of, 931 

diagnosis of, 932 

treatment of, 932 

intertiiictns or red gum, 931 

coiifertiis, 932 

alhidus or white gum, 932 
Strychnia in chorea, 611 

in infantile paralysis, 630 

in diphtheritic paralysis, 685 
Sucking, signs from mode of, 49 
Sudamiria in typhoid fever, 825, 829 
Sugar in urine in hooping-cough, 263 
Sulphurous applications in favus, 947 
Sulphur in treatment of scabies, 922 
Summer complaint {see cholera infantum), 421 
Suppurative lever in variola, 787, 799 
Swine-pox (see varicella). 

Sympathetic nerve, affection of, in cholera in- 
fantum, 429 
Syphilis, congenital, article on, 870-876 

modes of transmission of, to embryo, 870 

date of appearance of symptoms, 871 

condition of skin in, 871 

pemphigus and other eruptions in, 872 

coryza and stouiatitis in, 872 

alteration of voice in, 873 



1004: 



INDEX. 



Syphilis, rhagades and condylomata in, 873 

course of, 873 

development of tertiary stage, 873 

alteration of teeth in, described by Hutch- 
inson, 873 

interstitial keratitis in, 874 

affection of internal organs in, 874 

anatomical lesions in, 874 

diagnosis of, in early stage, 875 
in later stage, 875 
between inherited and acquired, 875 

prognosis in, 875 

treatment of, 876 

use of mercury in, 876 
Syphilis, transmitted by vaccination, 813 



Tabes mesenterica (see tuberculosis of mesen- 
teric glands), 846 
Table of mortality (see statistics). 
Tache meoingitique in meningitis, 491 
Taenia solium, 962 

lata, 963 
Tape-worm (see Tsenia), 962, 963 
Tarry applications in eczema, 913 i 

in scabies, 922 

in tinea, 952 ' 

in favus, 948 
Tartar emetic (xef; antimony). ' 

Tears, arrest of in disease, 27 j 

Teeth, alteration of in congenital syphilis, 873 ; 
Temperature, normal at different ages, 37 j 

tables of observations on, 37, 38 j 

effect of, on mortality of pneumonia and 
bronchitis, 162 

of body, low in cyanosis, 287 

in tubercular meningitis, 492 

lowered in infantile paralysis, 621 

in acute rheumatism, 647 

influence of, upon membranous croup, 89 

effect upon mortality of diphtheria and 
croup, 654 

in pulmonary phthisis, 850 

in scarlatina, 705 

in measles, 765 

in typhoid fever, 825, 827 

high, as cause of lichen, 933 

in sclerema, 957 

proper for sick-room, 776 
Tenotomy in infantile paralysis, 632 
Testicle, affected by metastasis in mumps, 688 
Tetanus nascentium. article on, 582-591 

definition and synonyms of, 582 

period of occurrence of, 583 

morbid conditions of umbilicus as cause 
of, 583 

Sims's view of displacement of occipital 
bone as cause of, 583 

general causes of, 583 

frequene_y of, 584 

anatomical lesions in, 585 

microscopic changes in spinal cord in, 586 

symptoms of, 586 

occurrence of paroxysm in, 587 

prognosis in, 588 

diagnosis of, 588 

duration of, occasionally chronic, 588 

prophylaxis in, 588 

treatment of, 589 

anaesthetics in, 589 

narcotics and antispasmodics in, 590 
Thermometer, observations with, in children, 
37 



Thread-worm (see ascaris vermicularis), 962 

(see tricocephalus dispar), 962 
Throat, examination of, 48 

diseases of (see pharyngitis), 348 , 
Thrush, article on, 321-344 

definition, synonyms of, 321 

frequency of, 321 

predisposing causes of, 321 

exciting causes of, 323 

anatomical lesions of, 323 

description of fungus of, 325 

symptoms of, 324 

nature of, 329 

diagnosis of, 330 

prognosis in, 330 

prophylactic treatment of, 330 

general treatment of, 331 

examination of cow's milk, 332 

mode of preparation of cow's milk, 335 

quantity of food necessary for children, 
335 

formula for gelatin food, 338 

examination of mother's milk, 341 

diet in, 341 

remedies useful in, 342 

local treatment of, 343 
Thymus gland, enlarged in laryngismus strid- 
ulus, 560 
Tinea lactea (see eczema capitis), 901 

granulata (see eczema granulatum), 904 

decalvans (see alopecia areata), 954 
tricupkytina, varieties of, 948 

identity of t. tonsurans and t. eircinata, 
948 

synonyms of, 948 

description of its fungus, tricophyton, 
939 

contagion as cause of, 948 

other causes of, 949 

general treatment in, 951 

local treatment in, 951 

epilation in, 951 

alkaline applications in, 951 

mercurial applications in, 952 

tarry applications in, 952 

cases of, 952 
tonsurans. 

eruption in, 949 

character of hairs in, 949 

condition of scalp in, 950 

diagnosis of, 950 

prognosis of, 950 
eircinata. 

eruption in, 950 

character of hairs in. 951 

diagnosis of, 951 
Tongue in scarlatina, 704 
Tonsils, sloughing of, in diphtheria, 661 

condition of, in scarlatina, 714 

acute inflammation of (see tonsillitis), 344 

chronic enlargement of, 346 

nature and causes of, 346 

anatomical appearances in, 346 

symptoms of, 346 

prognosis in, 347 

treatment of, 347 
Tonsillitis, 344 

definition of, 344 

symptoms of, 344 

causes and duration of, 345 

prognosis in, 345 

diagnosis of, 345 

treatment of, 345 



INDEX 



1005 



Tracheotomy, in membranous croup, 106 

statistics of its performance in different 
countries, lOfi-1 1 1 

estimation of its value, 110 

dangers of the operation, 110 

rules to guide in advising, 111, 117 

proper period for performing, 112 

indications for, 113 

influence of period of performance upon 
result, 113 

contraindications, 114-117 

age as a contraindication, 114 

successful cases at early age, 114 

extension of false membrane into the 
bronchia as a contraindication, 114 

negative results of auscultation, 115 

presence of pneumonia as a contraindica- 
tion. 116 
general diphtheria as a contraindica- 
tion, 117 

contraindicated in secondary forms of 
croup, IIT) 

twice successfully performed in same sub- 
ject. 118 

mode of performing, 118-122 

instruments required in performing, 118 

details about canulas, 119 

substitutes for canulas, 120 

question of fixing trachea in, 120 

excising piece of trachea in, 120 

mode of performing, 121 

emphysema of neck following, 122 

use of anaesthetics during, 122 

after-treatment, 122-126 

great importance of, 122 

modes of rendering inspired air moist, 123 

treatment of wound, 123 

instillation and atomization into trachea 
after, 124 

directions for cleansing tubes after, 124 

mode of removing canula, 124 

date of removing canula, 125 

causes of delay in removing canula, 125 

general after-treatment, 126 

importance and manner of feeding pa- 
tients. 126 

question of medication after, 127 

difficulty of deglutition following, 126 

illustrative cases of, 127 
Treatment of coryza, 58 

of simple laryngitis without spasm, 67 

of chronic laryngeal cough, 67 

of spasmodic simple laryngitis, 80 

of pseudo-membranous laryngitis, 99 

of atelectasis puhuonum, 142 

of collapse of the lung, 156 

of pneumonia, 186 

of bronchitis, 212 

of emphysema, 230 

of pleurisy, 243 

of pneumothorax, 258 

of hooping-cough, 270 

of complications in, 278 
of paroxysm of, 280 

of cyanosis, 289 

of acute pericarditis, 292 

of chronic pericarditis, 292 

of acute endocarditis, 293 

of chronic valvular disease, 298 

of erythematous stomatitis. 302 

of aphthse, 304 

of ulcerative stomatitis, 307 

of gangrene of the mouth, local, 317 



Treatment of gangrene of the mouth, general, 
320 

of thrush, 331 

of tonsillitis, 345 

of chronic enlargement of tonsils, 347 

of simple pharyngitis. 352 

of retro-pharyn^eal abscess, 355 

of indigestion, 362 

of simple diarrhoea, 373 

of gastritis, 382 

of entero-colitis. 403 

of cholera infantum, 434 

of dysentery, 444 

of diseases of coecum and appendix, 460 

of intussusception, 474 

of tubercular meningitis, 499 

of simple meningitis, 513 

of cerebral congestion, 518 

of cerebral hemorrhage, 527 

of chronic hydrocephalus, 535 
I of eclampsia, 550 

' of laryngismus stridulus, 568 

of contraction with rigidity, 577 
I of tetanus nascentium, 588 

I of chorea, 617 

of atrophic infantile paralysis, 629 
' of facial paralysis, 634 

of progressive muscular sclerosis, 645 

of acute rheumatism, 649 

of diphtheria, 678 

of mumps, 689 

of malarial fever, 692 

of rickets. 869 

of tuberculosis, 856 

of congenital syphilis, 876 

of scarlatina, 738 

of scarlatinous dropsy, 754 

of measles. 776 

of variola, 798 

of varicella, 821 

of typhoid fever, 833 

of scrofula, 840 

of erythema, 881 

of erysipelas, 888 

of roseola, 894 

of urticaria, 897 

of eczematous affections, 906 

of herpes, 918 

of scabies, 922 

of pemphigus, 925 

of rupia, 928 

of ecthyma, 930 

of strophulus, 932 

of lichen, 934 

of prurigo, 935 

of psoriasis. 936 

of pityriasis, 937 

of ichthyosis, 937 

of favus, 945 

of tinea, 951 

of alopecia areata, 955 

of sclerema, 959 

of ascaris lurabricoides, 972 

of ascaris verraicularis, 977 
Tricocephalus dispar, 962 
Tricophyton, description of {see tinea alsol, 

939 
Trismus (se-e tetanus). 

Trousseau, on tracheotomy in true croup, 107, 
108, 113, 117 

on paracentesis, 246-251 

on compression of the head in hydroceph- 
alus, 536 



1006 



INDEX. 



Tube-casts in urine in diphtheria, 672 

in scarlatina, 727 
Tubercular meningitis {see meninscitis), 479 
Tuberculosis, ns sequel of t,yphoid fever, 831 
* of measles, 772 

of hooping cough, 267 
of meninges (5^*^ meningitis), 479 
associated with scrofula, 836 
article on, 842-857 
causes of, 842 

relation of, to pneumonia, 842 
apt to involve several viscera simultane- 
ously. 843 
of bronchial glands, anatomical appear- 
ances of, 843 
of lungs, anatomical appearances of, 843 
of peritoneum, anatomical appearances 

of, 844 
of omentum, anatomical appearances of, 

845 
of mesenteric glands, anatomical appear- 
ances of, 846 
term used to include cheesy products not 

strictly tuberculous, 846 
of bronchial glands, symptoms of, 847 
characters of cough in, 847 
pressure on veins in. 847 
physical signs of, 847 
peculiarities of, 847 
pulmonary, symptoms of, 849 
importance of general symptoms in, 

849 
character of cough in, 849 
haemoptysis rare in, 850 
temperature in, 850 
peculiarities of physical signs in, 850 
pneumonia in, 851 
duration of, at times great, 852 
occasional recovery in. 852 
of peritoneum, symptoms of, obscure, 852 
digestive disturbances in, 852 
• pain in, 852 
enlargement of abdomen in, 852 
tumor when omentum is affected, 853 
course of, 853 
modes of death in, 853 
of mesenteric glands, symptoms of, 853 
enlargement of abdomen in, 853 
detection of tumor in, 853 
digestive disturbances in, 853 
duration of, 854 
diagnosis of, 854 

from remittent fever, 854 
from typhoid fever, 833 
pulmonary, diagnosis of, from chronic 

bronchitis, 854 
of peritoneum, diagnosis of. from simple 

distension of abdomen, 855 
of mesenteric glands, diagnosis of, from 

abdominal tumors, 855 
prognosis in, 855 
possibility of recovery from, 855 
modes of death in, 855 
treatment of, prophylactic, 856 

curative, 856 
use of tonics in, 856 
diet in, 856 
cod-liver oil in, 857 
treatment of complications, 857 
Tuberculous pneumonia, 851 

peritonitis (sci? tuberculosis of peritoneum). 
Tuckwell, on chorea, 593 



Tumor, abdominal, in diseases of coecum and 
appendix, 456 
in intussusception, 470 
in tuberculosis of mesenteric glands, 

853 
in tuberculosis of omentum, 853, 855 
diagnosis of, 855 

gummy, in congenital syphilis, 875 
Turpentine as a vermifuge, 973 
Turpeth mineral in pseudo-membranous laryn- 
gitis, 102 
Typhlitis, in article on diseases of coecum and 
appendix. 447-462 
synonyms of, 448 
seat and character of, 448 
causes of, 449 

anatomical appearances of, 452 
cases of, 454 
symptoms of, 455 

of perforation of the coecum during, 
457 
duration of, 458 
prognosis in, 458 
diagnosis of, 459 
treatment of, 460 
Typhoid fever, diagnosis from tubercular men- 
ingitis,. 494 
article on, 822-835 
formerly confounded with remittent fever, 

822 
causes of, 822 

but slightly contagious, 822 
epidemic nature of, 822 
anatomical appearances in, 823 
condition of intestine in, 823 
condition of blood in, 823 
condition of brain in, 823 
symptoms of ordinary cases, 824 
marked remissions in febrile action, 824 
prodromes in. 824, 825 
eruption in, 824. 826, 829 
symptoms of fully developed attack, 825 

of grave cases, 825 
favorable symptoms in, 826 
unfavorable symptoms in, 827 
digestive disturbances in, 824, 825, 827 
character of stools in. 828 
distension of abdomen in, 828 
enlargement of spleen in, 828 
urine in, 828, 831 
respiration in, 824, 825, 829 
pulse in, 829 

nervous symptoms in, 829 
pulmonary complications in, 830 
perforation of intestine in, 830 
intestinal hemorrhage in, 830 
albuminuria and oedema in, 831 
complicated with malaria or one of the 

eruptive fevers, 831 
tuberculosis as sequel of, 831 
convalescence in. 831 
relapses in, 826. 831 
duration of, 832 
prognosis and mortality in, 832 
diagnosis of, from gastro-enteritis, 832 
from typhoid pneumonia. 832 
from acute tubei-cu1osis, 833 
treatment of febrile symptoms in, 834 
of gastric irritability in. 834 
of intestinal symptoms in, 834 
of nervous symptoms in, 834 
of complications in, 834 
use of quinia in, 834 



INDEX. 



1007 



Typhoid fever, use of opium in, S35 
stimulants in, 835 
diet in, 835 
management of convalescence, 835 

Ulceration of internal malleoli in thrush, 329 

of mucous membrane of fauces in diph- 
theria, 659 
in scarlatina, 713 

in erythema intertrigo, 879 
Umbilicus, morbid states of, as cause of teta- 
nus. 583 
Umbilication of variolous pock, cause of, 794 
Ureemia, in scarlatinous dropsy, 725 
Urine in pneumonia, 181 

in bronchitis, 210 

in pleurisy, 239 

in hooping-cough, 263 

in chorea, 601 

in diphtheria, 668 

in rickets. 861 

in scarlatina, 704 

in scarlatinous dropsy, 726 

in measles, 764 

in variola, 788 

in tvphoid fever, 831 
Urticaria, article on, 894-898 

definition and synonyms of, 894 

forms of, 895 

causes of, 895 

symptoms of. 895 

diagnosis of, 896 

prognosis in, 897 

treatment of, 897 

diet in, 897 

Vaccina (.«^e vaccine disease). 
Vaccination {see under vaccine disease). 
Vaccine disease, article on, 804-819 
definition and synonyms of, 804 
history of, 804 
date of appearance and development of 

pock, 805 
cellular character of pock, 805 
local and general symptoms in, 806 
desiccation and desquamation in, 806 
character of cicatrix after, 806 
irregularities and course of, 807 
severe local symptoms in, 807 
erysipelas following, 884 
appearance of pock retarded, 808 
spurious form of, 808 
diagnosis of, 808 

protective power of against variola, 809 
cases illustrative of, 809 
against death, 815 
Vaecinatioyi, period of performing, 811 
susceptibility to, variable, 811 
eflPeet of cutaneous eruptions on, 812 
alleged transmission of cutaneous diseases 
by, 812 
of syphilis by, 813 
forms of virus employed, 814 
characters of good vaccine crust, 814 
modes of introducing virus, 814 
advantages of several punctures in, 815 
influence of number and quality of cica- 
trices on mortality after, 815 
mode of inserting virus, 818 
place of performing, 815, 819 
'Revarcivatioii, necessity for. 816 
results of, 817 
period of performance, 816 



Vaccinia {see vaccine disease). 
Vacuole {see bronchial abscess), 201 
Valerian in chorea, 610 
Valleix, plan of examining abdomen, 47 
expectoration in true croup, 95 " 
emetics in true croup, 100 
on tracheotomy in croup, 110 
expectoration in pneumonia, 178 
Valvular diseases of heart {see heart). 
Varicella, article on, 819-822 
definition of, 819 
synonyms of, 819 
forms'of, 819 
contagious nature of, 819 
epidemic nature of, 820 
essentially distinct from variola, 820 
symptoms of 820 
eruption in, 820 
diagnosis of, 821 
prognosis in, 821 
treatment of, 821 
Variola, article on, 781-804 
definition of, 781 
frequency of 781 
table of mortality of, 782 
forms of, 783 
contagious nature of, 783 
epidemic nature of, 783 
transmitted by fomites, 783 
regular form of, period of incubation in, 
783 
symptoms of initial stage, 784 
pain in the loins in, 784 
symptoms of eruptive stage of, 784 
discrete and confluent forms of, 785 
date of appearance of eruption in, and 

character of papules in, 784, 785 
development of eruption in, 785 
occurrence of eruption on mucous 

membranes, 786 
stomatitis in, 786 
laryngitis in, 786 

swelling of subcutaneous tissue in, 
787 
subsidence of general symptoms on ap- 
pearance of eruption, 787 
secondary fever, 787 
date of desiccation, 787 
date and modes of desquamation, 788 
pitting after, 788 
digestive symptoms during, 788 
urine in, 788 
excessive discharge of urine during 

desiccation, 789 
nervous symptoms in, 789 
irregular farms of, symptoms of initial 
stage, 789 
course of eruption in, 789 
hemorrhagic eruption in, 790 
modified {see varioloid), 791 
complications of 792 
anatomical lesions, 793 
condition of blood in, 793 

mucous membranes in, 793 
anatomy of pock in, 794 
diagnosis of, 794 
prognosis in, 797 
favorable symptoms in, 797 

unfavorable symptoms in, 797 
treatment of, 798-804 
mild febrifuges in mild cases, 798 
laxatives in, 799 



1008 



INDEX. 



Variola, remedies for favoring appearance of 
eruption in, 799 
diet in, 799 
quinia in, 799 
opium in, 799 
stimulants in, 799 
treatment of complications in, 800 

of ophthalmia. 800 
ventilation and disinfectants in, 801 
prevention of pitting in. 801-804 
cauteiization of pock with nitrate of sil- 
ver, 801 
mercurial applications in, 802 
applications of solution of gutta percha 
in, 80:^ 
Varioloid, definition of, 791 
symptoms of, 791 

course of eruption more rapid in, 792 
absence of secondary fever in, 792 

no pitting after, 792 
duration of, 792 
prognosis in. 797 
Venesection {see bleeding). 
Ventilation, importance of, in sick-chamber, 

776 
Vermifuges, 972-976 
Vesicles, chapter on, 898 

in variola, 785 
Virus, vaccine, forms of employed, and mode 

of introduction, 814 
Viscera, peculiar changes of in rickets, 867 
Voice, alteration of in coryza, 67 
in simple laryngitis, 64 
in false croup, 78 
in true croup. 93 
in diphtheritic paralysis, 675 
in congenital syphilis, 873 
Volvulus [see intussusception), 462 
Vomicae, rare in tuberculosis of lungs, 844 
Vomiting, diagnostic signs from, 50, 51 
in gastritis. 381 
in entero-colitis, 400 



Vomiting in entero-colitis, remedies for, 412 
in cholera infantum, 431 

treatment of, 436 
in intussusception. 468 
in typhoid fever, 424, 428 

Water, importance of administering in pneu- 
monia, 195 
in cholera infantum, 437 
injections of, in intussusception, 475 
external use of, in scarlatina {see also bath 

and affusion), 739, 742 
local use of, in eczema, 909 
Wells, case of chronic trismus, 588 
Wertheimer, on oedematous angina, 350 
West, C, on statistics of pneumonia, 159 
on cerebral congestion, 517 
on characteristics of bronchial phthisis, 
849 
Wilson, Erasmus, description of acarus scabiei, 

920 
AVoodward, J. J., on lesions in diarrhoea, 370 
micro.«;copic changes in intestine in entero- 
colitis, 395 
use of mercury in diarrhoea, 408 
Woorara in tetanus, 590 

Worms in the alimentary canal, chapter on, 
961-978 
varieties of, 961 

description of ascaris lumbricoides, 961 
of ascaris vermicularis, 962 
of tricocephalus dispar, 962 
of taenia solium, 962 
lata, 963 
frequency of, much exaggerated, 963 
dangerous symptoms from, 964 
Wormseed oil as a vermifuge, 972 
Wunderiich, on temperature in scarlatina, 
748 

Zona {see herpes zoster), 915 
Zymotic diseases, 651 



EREATUM. 

The reference on page 592 to Dr. George S. Gerhard's paper on Chorea 
should read, Phila. Med. Times, January 3d, 1874, p. 211. 



3477 
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